Provider First Line Business Practice Location Address:
528 PROSPECT PL
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:
11238-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-585-6493
Provider Business Practice Location Address Fax Number:
718-504-3881
Provider Enumeration Date:
08/14/2026