Provider First Line Business Practice Location Address:
1242 50TH 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:
11219-3540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-854-9406
Provider Business Practice Location Address Fax Number:
718-854-1885
Provider Enumeration Date:
08/26/2016