Provider First Line Business Practice Location Address:
JFK MEDPORT BLDG 14 WEST
Provider Second Line Business Practice Location Address:
SUITE 14A
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-656-1245
Provider Business Practice Location Address Fax Number:
718-656-3060
Provider Enumeration Date:
07/26/2006