Provider First Line Business Practice Location Address:
366 KINGS HWY
Provider Second Line Business Practice Location Address:
APT 2B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-435-9365
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2016