Provider First Line Business Practice Location Address:
16927 137TH AVE
Provider Second Line Business Practice Location Address:
ROCHDALE VILL. SHOPPING MALL #2
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11434-4517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-977-0300
Provider Business Practice Location Address Fax Number:
718-977-1230
Provider Enumeration Date:
10/17/2006