Provider First Line Business Practice Location Address:
713 HUMBOLDT ST
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:
11222-3506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-717-4429
Provider Business Practice Location Address Fax Number:
212-223-0198
Provider Enumeration Date:
02/04/2026