Provider First Line Business Practice Location Address:
1311 AVENUE U
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:
11229-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-382-4784
Provider Business Practice Location Address Fax Number:
718-998-2637
Provider Enumeration Date:
07/19/2005