Provider First Line Business Practice Location Address: 
6 COPENHAGEN CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COHOES
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12047-4968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-783-3053
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/19/2012