Provider First Line Business Practice Location Address:
347 BEACH 19TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-869-8888
Provider Business Practice Location Address Fax Number:
718-869-8893
Provider Enumeration Date:
08/28/2006