Provider First Line Business Practice Location Address:
190 BEACH 132 STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKAWAY PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11694
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-318-9117
Provider Business Practice Location Address Fax Number:
718-318-9117
Provider Enumeration Date:
06/07/2012