Provider First Line Business Practice Location Address:
612 E PENN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-3712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-330-6653
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/30/2010