Provider First Line Business Practice Location Address: 
5 ROCKHALL LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ROCKY POINT
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11778-9307
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
631-707-2151
    Provider Business Practice Location Address Fax Number: 
631-707-2151
    Provider Enumeration Date: 
05/01/2007