Provider First Line Business Practice Location Address: 
27 RUBY LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLAINVIEW
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11803-3811
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-822-1888
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/20/2012