Provider First Line Business Practice Location Address:
133-09 143RD ST
Provider Second Line Business Practice Location Address:
SOUTH OZONE PARK
Provider Business Practice Location Address City Name:
QUEENS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-427-1205
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2023