Provider First Line Business Practice Location Address: 
136 NORTHERN PKWY W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLAINVIEW
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11803-1933
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
516-375-9841
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/23/2014