Provider First Line Business Practice Location Address:
399 COUNTYLINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMITYVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-608-5629
Provider Business Practice Location Address Fax Number:
631-795-2975
Provider Enumeration Date:
10/28/2005