Provider First Line Business Practice Location Address:
1723 ELM AVE
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:
11230-5306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-413-5102
Provider Business Practice Location Address Fax Number:
718-425-0501
Provider Enumeration Date:
12/26/2025