Provider First Line Business Practice Location Address:
440-14 WAVERLY AVENUE
Provider Second Line Business Practice Location Address:
WAVERLY AVENUE CLINIC
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-654-2077
Provider Business Practice Location Address Fax Number:
631-654-8376
Provider Enumeration Date:
10/08/2010