Provider First Line Business Practice Location Address: 
4010 82ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELMHURST
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11373-1305
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-426-3333
    Provider Business Practice Location Address Fax Number: 
718-426-6387
    Provider Enumeration Date: 
02/26/2007