Provider First Line Business Practice Location Address:
136 E PARK AVE STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-3510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-200-4628
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2025