Provider First Line Business Practice Location Address: 
3041 AVENUE U
    Provider Second Line Business Practice Location Address: 
1ST FLOOR
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11229-5126
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-615-0049
    Provider Business Practice Location Address Fax Number: 
718-646-5315
    Provider Enumeration Date: 
09/09/2010