Provider First Line Business Practice Location Address: 
206 W THOMAS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROME
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13440-5008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-336-9190
    Provider Business Practice Location Address Fax Number: 
315-336-3121
    Provider Enumeration Date: 
04/08/2007