Provider First Line Business Practice Location Address:
475 IRVING AVE
Provider Second Line Business Practice Location Address:
SUITE 108
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-1756
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-671-0070
Provider Business Practice Location Address Fax Number:
315-475-0620
Provider Enumeration Date:
11/21/2006