Provider First Line Business Practice Location Address:
258 EAST 115TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10029-2031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-360-5939
Provider Business Practice Location Address Fax Number:
212-876-0338
Provider Enumeration Date:
07/20/2006