Provider First Line Business Practice Location Address: 
77 GENESEE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW HARTFORD
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
13413-2336
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
315-732-1600
    Provider Business Practice Location Address Fax Number: 
315-338-5407
    Provider Enumeration Date: 
08/18/2011