Provider First Line Business Practice Location Address: 
24 BANGOR ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
STATEN ISLAND
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10314-6202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
917-620-4202
    Provider Business Practice Location Address Fax Number: 
718-494-7715
    Provider Enumeration Date: 
09/09/2010