Provider First Line Business Practice Location Address:
9850 STATE ROUTE 4
Provider Second Line Business Practice Location Address:
LOT 1 BOX 51
Provider Business Practice Location Address City Name:
WHITEHALL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12887-2323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-824-1199
Provider Business Practice Location Address Fax Number:
518-824-1199
Provider Enumeration Date:
09/17/2009