Provider First Line Business Practice Location Address:
622 EAST PARK 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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-432-5195
Provider Business Practice Location Address Fax Number:
516-487-1253
Provider Enumeration Date:
12/13/2006