Provider First Line Business Practice Location Address:
1250 BROADWAY
Provider Second Line Business Practice Location Address:
VNSNY SPARK CARE 4TH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10001-3701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-630-5290
Provider Business Practice Location Address Fax Number:
212-290-0158
Provider Enumeration Date:
09/13/2012