Provider First Line Business Practice Location Address:
8912 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:
11236-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-916-2734
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2025