Provider First Line Business Practice Location Address: 
140 PROSPECT AVE STE 1
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HACKENSACK
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07601-2257
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-970-6833
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/15/2008