Provider First Line Business Practice Location Address: 
1111 FRANKLIN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARDEN CITY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11530-1617
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-663-1145
    Provider Business Practice Location Address Fax Number: 
929-455-9927
    Provider Enumeration Date: 
06/25/2018