Provider First Line Business Practice Location Address: 
1020 PARK AVE OFC NE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW YORK
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10028-0913
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-472-5558
    Provider Business Practice Location Address Fax Number: 
212-472-3552
    Provider Enumeration Date: 
02/26/2007