Provider First Line Business Practice Location Address:
17 W OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMITYVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11701-2960
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-608-1192
Provider Business Practice Location Address Fax Number:
631-608-2770
Provider Enumeration Date:
08/18/2010