Provider First Line Business Practice Location Address: 
1492 E 12TH ST APT 3A
    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: 
11230-6698
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
347-585-9676
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/05/2022