Provider First Line Business Practice Location Address:
114 SOUTH SHORE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OLD FORGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13420-0207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-369-6619
Provider Business Practice Location Address Fax Number:
315-369-6533
Provider Enumeration Date:
12/04/2006