Provider First Line Business Practice Location Address:
475 IRVING AVE
Provider Second Line Business Practice Location Address:
SUITE 320
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:
315-425-7822
Provider Business Practice Location Address Fax Number:
315-425-7885
Provider Enumeration Date:
11/17/2006