Provider First Line Business Practice Location Address:
139 WHITE BIRCH LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIAN LAKE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12842-0250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-648-6146
Provider Business Practice Location Address Fax Number:
518-648-6143
Provider Enumeration Date:
07/27/2010