Provider First Line Business Practice Location Address:
14930 88TH ST
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
HOWARD BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11414-1438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-323-0079
Provider Business Practice Location Address Fax Number:
718-323-9190
Provider Enumeration Date:
08/02/2005