Provider First Line Business Practice Location Address: 
249 KINGSLAND AVE
    Provider Second Line Business Practice Location Address: 
APT. 2
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11222-4304
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
614-581-0147
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/31/2012