Provider First Line Business Practice Location Address: 
1456 FULTON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11216-2607
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-636-4500
    Provider Business Practice Location Address Fax Number: 
341-729-6836
    Provider Enumeration Date: 
04/05/2006