Provider First Line Business Practice Location Address: 
1908 AVENUE K
    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: 
11230-4904
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-859-6786
    Provider Business Practice Location Address Fax Number: 
718-859-6783
    Provider Enumeration Date: 
12/14/2007