Provider First Line Business Practice Location Address: 
64 S WINDHORST AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BETHPAGE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11714-4929
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-865-2540
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/30/2012