Provider First Line Business Practice Location Address: 
91 GLENEIDA AVE
    Provider Second Line Business Practice Location Address: 
STE A
    Provider Business Practice Location Address City Name: 
CARMEL
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10512-1222
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-228-7000
    Provider Business Practice Location Address Fax Number: 
845-228-5485
    Provider Enumeration Date: 
07/12/2006