Provider First Line Business Practice Location Address: 
2 FALLKILL AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
POUGHKEEPSIE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12601-2104
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-242-6302
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/16/2011