Provider First Line Business Practice Location Address:
1206 LYDIG AVE REAR
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:
10461-1715
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-867-3043
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/28/2019