Provider First Line Business Practice Location Address:
2784 E 12TH ST
Provider Second Line Business Practice Location Address:
UNIT 4B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11235-4632
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-564-9961
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2012