Provider First Line Business Practice Location Address: 
455 NORTH END AVENUE, GROUND FLOOR
    Provider Second Line Business Practice Location Address: 
WELNESS CENTER
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10282-5383
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
917-522-1340
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/28/2017