Provider First Line Business Practice Location Address:
1811 AVENUE P STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11229-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-842-2000
Provider Business Practice Location Address Fax Number:
718-706-7447
Provider Enumeration Date:
06/22/2026