Provider First Line Business Practice Location Address:
120 W PARK AVE STE 312C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-3344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-724-8013
Provider Business Practice Location Address Fax Number:
516-724-8014
Provider Enumeration Date:
12/11/2025