Provider First Line Business Practice Location Address:
2840 JERUSALEM AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WANTAGH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-781-1141
Provider Business Practice Location Address Fax Number:
516-781-1184
Provider Enumeration Date:
02/28/2007