Provider First Line Business Practice Location Address: 
46 MILLAY LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAY SHORE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11706-4322
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-880-9219
    Provider Business Practice Location Address Fax Number: 
631-254-0536
    Provider Enumeration Date: 
11/14/2014