Provider First Line Business Practice Location Address:
118 OHIO AVE
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:
11561-1130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-526-6812
Provider Business Practice Location Address Fax Number:
718-780-4007
Provider Enumeration Date:
12/28/2010