Provider First Line Business Practice Location Address:
121 DEKALB AVENUE
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:
11201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-250-6604
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/19/2020