Provider First Line Business Practice Location Address: 
4 MEADOW DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STONY BROOK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11790-2810
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-741-4323
    Provider Business Practice Location Address Fax Number: 
631-751-6488
    Provider Enumeration Date: 
09/01/2005