Provider First Line Business Practice Location Address:
8428 ROOSEVELT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON HEIGHTS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11372-7341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-424-4989
Provider Business Practice Location Address Fax Number:
718-313-0464
Provider Enumeration Date:
10/06/2005