Provider First Line Business Practice Location Address:
2039 BATH AVE
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:
11214-4873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-513-4822
Provider Business Practice Location Address Fax Number:
718-513-4823
Provider Enumeration Date:
10/22/2025