Provider First Line Business Practice Location Address:
13618 242ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11422-1523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-569-7740
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/29/2026