Provider First Line Business Practice Location Address: 
365 EAST MAIN STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PATCHOGUE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11772
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-854-1266
    Provider Business Practice Location Address Fax Number: 
631-854-1329
    Provider Enumeration Date: 
08/05/2006