Provider First Line Business Practice Location Address:
118 E MAIN ST
Provider Second Line Business Practice Location Address:
PORT JERVIS MIDDLE SCHOOL
Provider Business Practice Location Address City Name:
PORT JERVIS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12771-2152
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-858-3100
Provider Business Practice Location Address Fax Number:
845-858-2761
Provider Enumeration Date:
12/13/2011