Provider First Line Business Practice Location Address: 
274 TOMPKINS STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CORTLAND
    Provider Business Practice Location Address State Name: 
WY
    Provider Business Practice Location Address Postal Code: 
13045
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
607-756-9886
    Provider Business Practice Location Address Fax Number: 
607-756-8939
    Provider Enumeration Date: 
09/28/2006