Provider First Line Business Practice Location Address:
218-11 JAMAICA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUEENS VILLAGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11428-2124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-464-1978
Provider Business Practice Location Address Fax Number:
718-464-1995
Provider Enumeration Date:
06/23/2005