Provider First Line Business Practice Location Address: 
141 N 4TH ST
    Provider Second Line Business Practice Location Address: 
2ND FLOOR
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11211-3216
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
212-989-2990
    Provider Business Practice Location Address Fax Number: 
212-792-6058
    Provider Enumeration Date: 
09/07/2010