Provider First Line Business Practice Location Address:
811 AVENUE U
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:
11223-4176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-382-1990
Provider Business Practice Location Address Fax Number:
718-382-1991
Provider Enumeration Date:
10/16/2012