Provider First Line Business Practice Location Address:
147 N COMRIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12095-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-762-4311
Provider Business Practice Location Address Fax Number:
518-762-5235
Provider Enumeration Date:
07/31/2017