Provider First Line Business Practice Location Address: 
765 STREETER HILL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JEFFERSON
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
12093
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
646-498-3049
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/14/2006