Provider First Line Business Practice Location Address:
22 HARRISON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13790-2142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-268-9314
Provider Business Practice Location Address Fax Number:
315-268-9255
Provider Enumeration Date:
01/16/2006