Provider First Line Business Practice Location Address:
840 SHORE RD
Provider Second Line Business Practice Location Address:
APT 1A
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-5405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-993-4399
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2012