Provider First Line Business Practice Location Address: 
142-01 37TH AVENUE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FLUSHING
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11354
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-461-7788
    Provider Business Practice Location Address Fax Number: 
718-461-3343
    Provider Enumeration Date: 
03/31/2006