Provider First Line Business Practice Location Address: 
1208 PELHAM PKWY S
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRONX
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
10461-1029
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-780-2631
    Provider Business Practice Location Address Fax Number: 
212-777-5893
    Provider Enumeration Date: 
11/30/2006