Provider First Line Business Practice Location Address:
199-12 HOLLIS AVENUE
Provider Second Line Business Practice Location Address:
1ST FL
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11412-1232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-413-5665
Provider Business Practice Location Address Fax Number:
718-413-5650
Provider Enumeration Date:
10/17/2011