Provider First Line Business Practice Location Address:
39 LASALLE AVE APT 109
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUFFALO
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14214-1453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-930-9698
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2025