Provider First Line Business Practice Location Address:
114 DITMAS AVE STE B
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:
11218-4902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-851-7778
Provider Business Practice Location Address Fax Number:
718-851-7090
Provider Enumeration Date:
09/02/2025