Provider First Line Business Practice Location Address:
144-29 183RD STREET
Provider Second Line Business Practice Location Address:
2ND UNIT
Provider Business Practice Location Address City Name:
SPRINGFIELD GARDENS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11413-1141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-534-8378
Provider Business Practice Location Address Fax Number:
347-534-8378
Provider Enumeration Date:
07/19/2017