Provider First Line Business Practice Location Address:
1407 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-998-6684
Provider Business Practice Location Address Fax Number:
718-998-0513
Provider Enumeration Date:
10/23/2006