Provider First Line Business Practice Location Address:
121 DEKALB AVE
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:
11201-5425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-777-5164
Provider Business Practice Location Address Fax Number:
703-890-2650
Provider Enumeration Date:
10/28/2013