Provider First Line Business Practice Location Address: 
625 MONTAUK HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CENTER MORICHES
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11934
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-878-7134
    Provider Business Practice Location Address Fax Number: 
631-878-5118
    Provider Enumeration Date: 
04/24/2016