Provider First Line Business Practice Location Address: 
108 MONTROSE AVENUE
    Provider Second Line Business Practice Location Address: 
PS 250
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11206-2008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-384-0889
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/28/2012