Provider First Line Business Practice Location Address:
274 S 2ND ST APT 20
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:
11211-5425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-489-2992
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2026