Provider First Line Business Practice Location Address:
242 BEACH 20TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAR ROCKAWAY
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11691
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-471-5500
Provider Business Practice Location Address Fax Number:
718-471-0734
Provider Enumeration Date:
07/25/2022