Provider First Line Business Practice Location Address: 
1213 WEST AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
OCEAN CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
08226-3265
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
609-545-8024
    Provider Business Practice Location Address Fax Number: 
609-840-6072
    Provider Enumeration Date: 
08/31/2022