Provider First Line Business Practice Location Address:
596 PROSPECT PL
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:
11238-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-239-1405
Provider Business Practice Location Address Fax Number:
718-319-1249
Provider Enumeration Date:
01/15/2010