Provider First Line Business Practice Location Address:
5 JOHNSON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-3096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-782-1181
Provider Business Practice Location Address Fax Number:
518-782-9171
Provider Enumeration Date:
12/06/2005