Provider First Line Business Practice Location Address:
1412 WANTAGH AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WANTAGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11793-2204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-409-1122
Provider Business Practice Location Address Fax Number:
516-409-0036
Provider Enumeration Date:
05/04/2007