Provider First Line Business Practice Location Address:
52-02 5TH STREET
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LONG ISLAND CITY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-530-6539
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2015