Provider First Line Business Practice Location Address: 
545 SAINT PAULS PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRONX
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10456-2122
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-992-6881
    Provider Business Practice Location Address Fax Number: 
718-992-0055
    Provider Enumeration Date: 
04/24/2010