Provider First Line Business Practice Location Address:
48 ESSEX ST
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:
11208-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-912-4250
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/17/2025