Provider First Line Business Practice Location Address:
153 LAKE SHORE RD
Provider Second Line Business Practice Location Address:
PHOENIX HOUSE MEDICAL DEPT
Provider Business Practice Location Address City Name:
RONKONKOMA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11779
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-471-5666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/27/2006