Provider First Line Business Practice Location Address: 
5925 15TH 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: 
11219-5009
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-972-2700
    Provider Business Practice Location Address Fax Number: 
718-972-2701
    Provider Enumeration Date: 
06/27/2005