Provider First Line Business Practice Location Address:
3051 LONG BEACH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCEANSIDE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11572-3240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-764-5142
Provider Business Practice Location Address Fax Number:
516-763-7420
Provider Enumeration Date:
11/22/2005