Provider First Line Business Practice Location Address:
282 AVENUE X
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:
11223-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-969-2060
Provider Business Practice Location Address Fax Number:
347-312-5082
Provider Enumeration Date:
10/29/2025