Provider First Line Business Practice Location Address:
1226 31ST AVE
Provider Second Line Business Practice Location Address:
BASEMENT NYC DOHMH
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11106-4814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-267-2104
Provider Business Practice Location Address Fax Number:
718-267-2105
Provider Enumeration Date:
12/11/2010