Provider First Line Business Practice Location Address:
151 INTREPID LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13205-2552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-469-8191
Provider Business Practice Location Address Fax Number:
315-469-4482
Provider Enumeration Date:
11/29/2005