Provider First Line Business Practice Location Address: 
1273 E 48TH ST
    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: 
11234-2101
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
917-796-0343
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/24/2010