Provider First Line Business Practice Location Address:
1383 DEAN ST
Provider Second Line Business Practice Location Address:
APT 3E
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11216-3450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-750-7170
Provider Business Practice Location Address Fax Number:
800-742-2541
Provider Enumeration Date:
12/08/2011