Provider First Line Business Practice Location Address:
1366 56TH ST
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:
11219-4616
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-854-0454
Provider Business Practice Location Address Fax Number:
718-633-7053
Provider Enumeration Date:
10/25/2011