Provider First Line Business Practice Location Address:
79 HALSEY ST
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:
07102-3052
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
646-251-8770
Provider Business Practice Location Address Fax Number:
917-970-4792
Provider Enumeration Date:
02/25/2026