Provider First Line Business Practice Location Address:
164TH STREET
Provider Second Line Business Practice Location Address:
82-68, QUEENS HOSPITAL CENTER, ROOM 2B-21
Provider Business Practice Location Address City Name:
JAMAICA
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-883-4037
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/16/2021