Provider First Line Business Practice Location Address:
16-15 9 STREET
Provider Second Line Business Practice Location Address:
PRIVATE HOUSE
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-204-0233
Provider Business Practice Location Address Fax Number:
718-204-0234
Provider Enumeration Date:
04/28/2009