Provider First Line Business Practice Location Address:
112 ALEXANDER AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAKE GROVE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11755-0429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-265-6655
Provider Business Practice Location Address Fax Number:
631-265-9735
Provider Enumeration Date:
10/16/2005