Provider First Line Business Practice Location Address:
1441 SOUTH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10314-3779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-226-1582
Provider Business Practice Location Address Fax Number:
718-227-5814
Provider Enumeration Date:
03/19/2026