Provider First Line Business Practice Location Address:
141 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11559-1669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-812-5066
Provider Business Practice Location Address Fax Number:
718-795-1966
Provider Enumeration Date:
12/29/2005