Provider First Line Business Practice Location Address: 
142 JORALEMON ST
    Provider Second Line Business Practice Location Address: 
FIRST FLOOR
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11201-4747
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-624-3003
    Provider Business Practice Location Address Fax Number: 
718-624-7517
    Provider Enumeration Date: 
12/04/2006