Provider First Line Business Practice Location Address:
1919 HAZEN ST
Provider Second Line Business Practice Location Address:
RMSC, RIKERS ISLAND, NYCD (NEW YORK CORRECTION DEPT)
Provider Business Practice Location Address City Name:
EAST ELMHURST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11370-1349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-774-7620
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2010