Provider First Line Business Practice Location Address: 
1793 AMSTERDAM AVE FL 1
    Provider Second Line Business Practice Location Address: 
1793 A,MSTERDAM AVENUE FL 1
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10031-3501
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-234-9746
    Provider Business Practice Location Address Fax Number: 
212-234-2747
    Provider Enumeration Date: 
04/10/2013