Provider First Line Business Practice Location Address:
104 DEKALB AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201-5427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-250-0060
Provider Business Practice Location Address Fax Number:
718-852-0469
Provider Enumeration Date:
01/30/2010