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Delmar Center For Rehabilitation And Nursing
125 Rockefeller Road • Delmar, NY 12054
Personal Information
Full Name
*
Address
Zip code
Phone Number
Email Address
*
Transaction Details
$
Amount
*
Description
Repeated Payments
Ongoing
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10 Months
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24 Months
36 Months
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Delmar Center For Rehabilitation And Nursing
125 Rockefeller Road
Delmar, NY 12054
Tell: (518) 621-1200
[response]
ID #[transid]
[created]
[cardholder]
$ [amount]
[cardtype] [ccnum4]
Authorization Number
[authcode]
AVS Response
[avsresult]
CVV response
[cvcresult]
[otherTransaction]
