Provider First Line Business Practice Location Address: 
242 E 72ND ST STE 1C
    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: 
10021-4574
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-744-4165
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/18/2011