Provider First Line Business Practice Location Address:
49-04 19TH AVE,
Provider Second Line Business Practice Location Address:
RIKERS ISLAND CORRECTIONAL FACILITY
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-774-7295
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2014