Provider First Line Business Practice Location Address: 
40 44 82ND STREET
    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: 
718-429-3800
    Provider Business Practice Location Address Fax Number: 
718-429-4224
    Provider Enumeration Date: 
12/19/2006