Provider First Line Business Practice Location Address:
610 HENRY ST
Provider Second Line Business Practice Location Address:
PS 146, LICH CLINIC, ROOM 209
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11231-2612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-923-4624
Provider Business Practice Location Address Fax Number:
718-923-4632
Provider Enumeration Date:
09/08/2007