Provider First Line Business Practice Location Address:
39 OLD MILITARY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-524-3660
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/30/2018