Provider First Line Business Practice Location Address: 
25 VAIL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
POUGHKEEPSIE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12603-6707
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-473-0150
    Provider Business Practice Location Address Fax Number: 
845-473-4204
    Provider Enumeration Date: 
09/10/2009