Provider First Line Business Practice Location Address:
12425 LUCAS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD GARDENS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11413-1526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-262-7125
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2026