Provider First Line Business Practice Location Address:
459 E 149TH ST STE A104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10455-1789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-381-8350
Provider Business Practice Location Address Fax Number:
212-381-8351
Provider Enumeration Date:
07/28/2025