Provider First Line Business Practice Location Address:
173A LAMPED LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10314-5835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-844-9119
Provider Business Practice Location Address Fax Number:
718-844-9119
Provider Enumeration Date:
04/05/2025