Provider First Line Business Practice Location Address:
1262 OCEAN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11230-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-859-5843
Provider Business Practice Location Address Fax Number:
718-859-6250
Provider Enumeration Date:
11/09/2005