Provider First Line Business Practice Location Address:
1717 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11229-1013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-240-7864
Provider Business Practice Location Address Fax Number:
347-240-7863
Provider Enumeration Date:
12/01/2025