Provider First Line Business Practice Location Address: 
5 E 98TH ST
    Provider Second Line Business Practice Location Address: 
2ND 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: 
10029-6501
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-241-9393
    Provider Business Practice Location Address Fax Number: 
212-241-3023
    Provider Enumeration Date: 
03/02/2006