Provider First Line Business Practice Location Address:
111 BUSHWICK AVENUE
Provider Second Line Business Practice Location Address:
BLOCK 2790 LOT 27
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-500-2389
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/05/2014