Provider First Line Business Practice Location Address:
2712 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:
11229-5052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-769-7403
Provider Business Practice Location Address Fax Number:
718-769-7440
Provider Enumeration Date:
10/13/2005