Provider First Line Business Practice Location Address:
195 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07103-3921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-824-8664
Provider Business Practice Location Address Fax Number:
973-824-9157
Provider Enumeration Date:
04/30/2026