Provider First Line Business Practice Location Address:
180 EAST PENN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-4264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-431-2277
Provider Business Practice Location Address Fax Number:
516-431-8596
Provider Enumeration Date:
08/23/2006