Provider First Line Business Practice Location Address:
645 WEST BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11561-2902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-889-1100
Provider Business Practice Location Address Fax Number:
516-431-0398
Provider Enumeration Date:
10/04/2006