Provider First Line Business Practice Location Address:
880 SUMMIT AVE APT 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:
07307-4804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
929-335-4832
Provider Business Practice Location Address Fax Number:
862-367-8792
Provider Enumeration Date:
04/15/2026