Provider First Line Business Practice Location Address:
840 54TH ST
Provider Second Line Business Practice Location Address:
HOUSE
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11220-3209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-633-6850
Provider Business Practice Location Address Fax Number:
212-226-9810
Provider Enumeration Date:
04/28/2011