Provider First Line Business Practice Location Address:
1422 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:
11229-3320
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-645-1227
Provider Business Practice Location Address Fax Number:
718-645-7454
Provider Enumeration Date:
08/02/2005