Provider First Line Business Practice Location Address:
25-10 30TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG ISLAND CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-879-1651
Provider Business Practice Location Address Fax Number:
718-267-6578
Provider Enumeration Date:
10/31/2008