Provider First Line Business Practice Location Address:
828 E 149TH ST STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10455-4670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-847-8401
Provider Business Practice Location Address Fax Number:
347-597-9157
Provider Enumeration Date:
12/15/2025