Provider First Line Business Practice Location Address:
8942 221ST ST
Provider Second Line Business Practice Location Address:
MANAGED CARE D101
Provider Business Practice Location Address City Name:
QUEENS VILLAGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11427-2508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-464-1019
Provider Business Practice Location Address Fax Number:
718-464-1019
Provider Enumeration Date:
09/25/2006