Provider First Line Business Practice Location Address: 
2833 OCEAN PKWY
    Provider Second Line Business Practice Location Address: 
SUITE 'A'
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11235-7857
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-372-4693
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/12/2006