Provider First Line Business Practice Location Address:
1309 AVENUE P
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:
11229-1164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-648-2162
Provider Business Practice Location Address Fax Number:
718-645-1148
Provider Enumeration Date:
05/31/2006