Provider First Line Business Practice Location Address: 
518 MCDONALD AVE
    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: 
11218-3816
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-633-4677
    Provider Business Practice Location Address Fax Number: 
718-686-1114
    Provider Enumeration Date: 
05/17/2006