Provider First Line Business Practice Location Address: 
1100 CONEY ISLAND AVENUE
    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: 
11230-2343
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-434-7572
    Provider Business Practice Location Address Fax Number: 
718-434-7703
    Provider Enumeration Date: 
05/19/2009