Provider First Line Business Practice Location Address: 
2225 BEECH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WANTAGH
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11793-4256
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-221-6248
    Provider Business Practice Location Address Fax Number: 
516-221-6248
    Provider Enumeration Date: 
12/27/2012