Provider First Line Business Practice Location Address:
143 AVENUE O STE C1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11204-4972
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-232-0572
Provider Business Practice Location Address Fax Number:
718-232-0604
Provider Enumeration Date:
10/11/2012