Provider First Line Business Practice Location Address: 
98120 QUEENS BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 1JK
    Provider Business Practice Location Address City Name: 
REGO PARK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11374-4357
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-896-4434
    Provider Business Practice Location Address Fax Number: 
718-897-1114
    Provider Enumeration Date: 
09/09/2010