Provider First Line Business Practice Location Address: 
15 W 72ND ST APT 1E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10023-3419
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-988-0402
    Provider Business Practice Location Address Fax Number: 
347-244-7212
    Provider Enumeration Date: 
08/15/2005