Provider First Line Business Practice Location Address:
21 S 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07206-1115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-248-3857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/19/2026