Provider First Line Business Practice Location Address:
92-29 QUEENS BLVD.
Provider Second Line Business Practice Location Address:
SUITE 2B
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-1072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-606-6912
Provider Business Practice Location Address Fax Number:
718-606-6914
Provider Enumeration Date:
02/28/2010