Provider First Line Business Practice Location Address: 
135 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HEMPSTEAD
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11550-2414
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-708-0243
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/24/2025