Provider First Line Business Practice Location Address: 
9215 147TH PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JAMAICA
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11435-4312
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-658-0742
    Provider Business Practice Location Address Fax Number: 
718-739-0789
    Provider Enumeration Date: 
02/13/2007