Provider First Line Business Practice Location Address: 
95 ALLENS CREEK ROAD
    Provider Second Line Business Practice Location Address: 
BUILDING 2, SUITE 203
    Provider Business Practice Location Address City Name: 
ROCHESTER
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14618
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-358-0258
    Provider Business Practice Location Address Fax Number: 
585-304-7450
    Provider Enumeration Date: 
03/13/2018