Provider First Line Business Practice Location Address:
28 GEORGIA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-1236
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-909-5988
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2005