Provider First Line Business Practice Location Address:
1115 WILLMOHR ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11212-2646
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-872-3754
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/29/2026