Provider First Line Business Practice Location Address: 
187 LAKE AVE STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT JAMES
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11780-2933
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-335-1569
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/18/2006