Provider First Line Business Practice Location Address: 
3110 QUEENS BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 301
    Provider Business Practice Location Address City Name: 
LONG ISLAND CITY
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11101-3002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-593-4121
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/09/2012