Provider First Line Business Practice Location Address:
42-23 212 STREET
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
BAYSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-224-6528
Provider Business Practice Location Address Fax Number:
718-224-8964
Provider Enumeration Date:
12/09/2013