Provider First Line Business Practice Location Address:
430 E 149TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10455-1338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-590-0831
Provider Business Practice Location Address Fax Number:
347-590-0833
Provider Enumeration Date:
09/24/2009