Provider First Line Business Practice Location Address:
632 W 147TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10031-4318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-234-5678
Provider Business Practice Location Address Fax Number:
212-234-5678
Provider Enumeration Date:
04/12/2007