Provider First Line Business Practice Location Address:
220 W 121ST ST
Provider Second Line Business Practice Location Address:
MEDICAL ROOM 136
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10027-6217
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-678-2865
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/03/2012