Provider First Line Business Practice Location Address:
622 WEST 168TH STREET, MHB-8 SO. KNUCKLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-305-6384
Provider Business Practice Location Address Fax Number:
212-305-5476
Provider Enumeration Date:
08/28/2006