Provider First Line Business Practice Location Address: 
20 W 74TH ST
    Provider Second Line Business Practice Location Address: 
RM #2
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10023-2401
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-873-0725
    Provider Business Practice Location Address Fax Number: 
212-362-6967
    Provider Enumeration Date: 
08/02/2006