Provider First Line Business Practice Location Address:
192 12TH ST APT 1
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:
11215-3918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-853-2073
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/16/2026