Provider First Line Business Practice Location Address:
12116 POWELLS COVE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE POINT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11356-1297
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-508-1879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2026