Provider First Line Business Practice Location Address: 
1911 AVENUE L
    Provider Second Line Business Practice Location Address: 
LOWER LEVEL
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11230-5002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
347-603-5656
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/27/2015