Provider First Line Business Practice Location Address:
6 WELLNESS WAY STE G12
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-2156
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-213-0305
Provider Business Practice Location Address Fax Number:
518-213-0679
Provider Enumeration Date:
10/03/2005