Provider First Line Business Practice Location Address: 
6651 GROVELAND HILL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GROVELAND
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
14462-9514
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
585-737-1640
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/28/2012