Provider First Line Business Practice Location Address:
800 IRVING AVE RM A202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SYRACUSE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13210-2716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-425-4657
Provider Business Practice Location Address Fax Number:
315-425-2647
Provider Enumeration Date:
10/11/2006