Provider First Line Business Practice Location Address:
339 HICKS ST
Provider Second Line Business Practice Location Address:
AT LONG ISLAND COLLEGE HOSPITAL 7TH FLR OTHMER
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201-5509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-780-1118
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/21/2007