Provider First Line Business Practice Location Address: 
345 WEBSTER AVE
    Provider Second Line Business Practice Location Address: 
6I
    Provider Business Practice Location Address City Name: 
BROOKLYN
    Provider Business Practice Location Address State Name: 
NY
    Provider Business Practice Location Address Postal Code: 
11230-1450
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
347-249-5814
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/28/2014