Provider First Line Business Practice Location Address:
2349 ELLIS AVE
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:
10462-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-828-5275
Provider Business Practice Location Address Fax Number:
718-828-5275
Provider Enumeration Date:
08/01/2011