Provider First Line Business Practice Location Address: 
680 MAIN ST
    Provider Second Line Business Practice Location Address: 
SUITE2
    Provider Business Practice Location Address City Name: 
PORT JEFFERSON
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11777-2203
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-474-8626
    Provider Business Practice Location Address Fax Number: 
531-474-8626
    Provider Enumeration Date: 
03/07/2008