Provider First Line Business Practice Location Address:
119 BEACH 129 ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKAWAY PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-486-7374
Provider Business Practice Location Address Fax Number:
718-486-6927
Provider Enumeration Date:
08/15/2005