Provider First Line Business Practice Location Address:
20 PROSPECT ST STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALLSTON SPA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12020-1367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-300-3952
Provider Business Practice Location Address Fax Number:
518-864-1694
Provider Enumeration Date:
07/18/2014