Provider First Line Business Practice Location Address: 
1100 PARK AVE
    Provider Second Line Business Practice Location Address: 
S 1B
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10128-1202
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-410-0878
    Provider Business Practice Location Address Fax Number: 
212-410-0957
    Provider Enumeration Date: 
04/11/2007