Provider First Line Business Practice Location Address:
1225 AVENUE R
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:
11229-1053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-376-6707
Provider Business Practice Location Address Fax Number:
718-376-6707
Provider Enumeration Date:
11/21/2005