Provider First Line Business Practice Location Address:
1825 PARK AVE
Provider Second Line Business Practice Location Address:
CLINIC 3, EIGHTH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10035-1641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-774-3230
Provider Business Practice Location Address Fax Number:
212-987-0484
Provider Enumeration Date:
10/15/2007