Provider First Line Business Practice Location Address:
1211 AVENUE U
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:
11229-4108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-382-9616
Provider Business Practice Location Address Fax Number:
718-382-9615
Provider Enumeration Date:
06/18/2013