Provider First Line Business Practice Location Address: 
550 NEWARK AVE
    Provider Second Line Business Practice Location Address: 
#308
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07306-1326
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-239-9500
    Provider Business Practice Location Address Fax Number: 
201-239-8200
    Provider Enumeration Date: 
12/20/2007