Provider First Line Business Practice Location Address: 
1421 3RD AVE
    Provider Second Line Business Practice Location Address: 
FIRST FLOOR
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10028-1802
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-744-5538
    Provider Business Practice Location Address Fax Number: 
212-744-4767
    Provider Enumeration Date: 
09/16/2006