Provider First Line Business Practice Location Address:
105 JOHNSON ST
Provider Second Line Business Practice Location Address:
ROOM 138 A
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201-2915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-625-6130
Provider Business Practice Location Address Fax Number:
718-596-9434
Provider Enumeration Date:
03/14/2012