Provider First Line Business Practice Location Address:
275 LAKE AVE # 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14608-1042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-530-0624
Provider Business Practice Location Address Fax Number:
585-270-4625
Provider Enumeration Date:
04/13/2026