Provider First Line Business Practice Location Address:
1110 PENNSYLVANIA AVE
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11207-9061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-649-6677
Provider Business Practice Location Address Fax Number:
718-272-0291
Provider Enumeration Date:
10/19/2005