Provider First Line Business Practice Location Address:
1766 E 12TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11229-1014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-743-0505
Provider Business Practice Location Address Fax Number:
718-339-0760
Provider Enumeration Date:
10/12/2015