Provider First Line Business Practice Location Address:
4913 VERNON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG ISLAND CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11101-5725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-392-4982
Provider Business Practice Location Address Fax Number:
718-392-4022
Provider Enumeration Date:
05/23/2005