Provider First Line Business Practice Location Address: 
41 N ALLEN ST
    Provider Second Line Business Practice Location Address: 
PINE HILLS ELEMENTARY SCHOOL
    Provider Business Practice Location Address City Name: 
ALBANY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12203-1601
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
518-475-6738
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/16/2011