Provider First Line Business Practice Location Address:
610 WEST 112TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10025-1898
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-875-4683
Provider Business Practice Location Address Fax Number:
212-875-4566
Provider Enumeration Date:
12/23/2008