Provider First Line Business Practice Location Address:
1122 AVENUE L
Provider Second Line Business Practice Location Address:
APT #2
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11230-4808
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-951-1227
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/19/2009