Provider First Line Business Practice Location Address: 
1991 MARCUS AVENUE
    Provider Second Line Business Practice Location Address: 
SUITE 110
    Provider Business Practice Location Address City Name: 
LAKE SUCCESS
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11042-2057
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-466-4700
    Provider Business Practice Location Address Fax Number: 
516-466-4810
    Provider Enumeration Date: 
12/27/2005