Provider First Line Business Practice Location Address:
1740 CONEY ISLAND AVE
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:
11230-6502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-375-0090
Provider Business Practice Location Address Fax Number:
718-375-3503
Provider Enumeration Date:
08/17/2005