Provider First Line Business Practice Location Address: 
264 W CRAIG HILL DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROCHESTER
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14626-3426
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-978-5475
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/22/2014