Provider First Line Business Practice Location Address:
19316 US ROUTE 11 STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-6736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-782-0136
Provider Business Practice Location Address Fax Number:
315-782-7212
Provider Enumeration Date:
06/06/2006