Provider First Line Business Practice Location Address: 
3610 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AMHERST
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14226-3123
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
716-200-4122
    Provider Business Practice Location Address Fax Number: 
716-783-8825
    Provider Enumeration Date: 
12/22/2011