Provider First Line Business Practice Location Address:
549 SOUTHERN BLVD
Provider Second Line Business Practice Location Address:
MEDICAL OFFICE
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10455-3762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-665-8705
Provider Business Practice Location Address Fax Number:
718-665-8705
Provider Enumeration Date:
08/11/2006