Provider First Line Business Practice Location Address:
421 EAST 149TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10455-3904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-401-3668
Provider Business Practice Location Address Fax Number:
718-401-3888
Provider Enumeration Date:
12/12/2013