Provider First Line Business Practice Location Address:
475 WATERVLIET SHAKER RD
Provider Second Line Business Practice Location Address:
SHAKER JUNIOR HIGH SCHOOL
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-4622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-785-1341
Provider Business Practice Location Address Fax Number:
518-785-2768
Provider Enumeration Date:
03/08/2012