Provider First Line Business Practice Location Address:
104 PADDOCK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13601-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-782-0415
Provider Business Practice Location Address Fax Number:
315-786-0417
Provider Enumeration Date:
10/02/2014