Provider First Line Business Practice Location Address:
192 MILL POND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12946-6607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-523-7173
Provider Business Practice Location Address Fax Number:
518-523-1768
Provider Enumeration Date:
01/30/2007