Provider First Line Business Practice Location Address: 
159 BARNEGAT RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
POUGHKEEPSIE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12601-5401
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-592-4915
    Provider Business Practice Location Address Fax Number: 
845-592-4914
    Provider Enumeration Date: 
12/01/2014