Provider First Line Business Practice Location Address:
100 PATRIOTS ROAD
Provider Second Line Business Practice Location Address:
LONG ISLAND STATE VETERANS HOME
Provider Business Practice Location Address City Name:
STONYBROOK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11790
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-444-8788
Provider Business Practice Location Address Fax Number:
631-444-8787
Provider Enumeration Date:
10/05/2006