Provider First Line Business Practice Location Address: 
228 WALKER PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WEST HEMPSTEAD
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11552-3236
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-481-9772
    Provider Business Practice Location Address Fax Number: 
516-481-9772
    Provider Enumeration Date: 
10/31/2006