Provider First Line Business Practice Location Address: 
606 OLD ROUTE 17
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MONTICELLO
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12701-7013
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-707-8312
    Provider Business Practice Location Address Fax Number: 
845-707-8319
    Provider Enumeration Date: 
12/08/2011