Provider First Line Business Practice Location Address: 
143 HUGHES PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ALBERTSON
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11507-1601
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
917-592-7158
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/19/2013