Provider First Line Business Practice Location Address:
5765 AMBOY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10309-3135
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-689-2795
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2026