Provider First Line Business Practice Location Address:
392 11TH ST
Provider Second Line Business Practice Location Address:
APT 6B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11215-4031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-832-2155
Provider Business Practice Location Address Fax Number:
718-630-3763
Provider Enumeration Date:
11/27/2006