Provider First Line Business Practice Location Address: 
292 SAINT PAULS AVE FL 2
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07306-5009
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
217-619-3025
    Provider Business Practice Location Address Fax Number: 
718-463-8880
    Provider Enumeration Date: 
07/25/2011