Provider First Line Business Practice Location Address: 
133 MORNINGSIDE AVE
    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: 
10027
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-923-2525
    Provider Business Practice Location Address Fax Number: 
212-222-6397
    Provider Enumeration Date: 
03/29/2007