Provider First Line Business Practice Location Address:
1674 48TH 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:
11204-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-512-4501
Provider Business Practice Location Address Fax Number:
718-871-0931
Provider Enumeration Date:
03/14/2026