Provider First Line Business Practice Location Address:
235-20 147TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEDALE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-894-9860
Provider Business Practice Location Address Fax Number:
347-894-9878
Provider Enumeration Date:
02/22/2007