Provider First Line Business Practice Location Address: 
7020 ROCKAWAY BEACH BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ARVERNE
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11692-1272
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-318-6285
    Provider Business Practice Location Address Fax Number: 
718-318-6440
    Provider Enumeration Date: 
08/31/2011