Provider First Line Business Practice Location Address:
41 S PERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSTOWN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-893-1687
Provider Business Practice Location Address Fax Number:
518-863-3075
Provider Enumeration Date:
09/24/2006