Provider First Line Business Practice Location Address:
1216 AVENUE J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11230-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-280-7814
Provider Business Practice Location Address Fax Number:
718-280-7815
Provider Enumeration Date:
07/07/2025