Provider First Line Business Practice Location Address:
62 WALLER AVENUE
Provider Second Line Business Practice Location Address:
SECOND FLOOR WELL ON THE WAY ROOM
Provider Business Practice Location Address City Name:
WHITE PLAINS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-500-3712
Provider Business Practice Location Address Fax Number:
914-834-0904
Provider Enumeration Date:
12/06/2007