Provider First Line Business Practice Location Address:
55 BARN RD
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946-1050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-302-1951
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2007