Provider First Line Business Practice Location Address:
240 MOUNT VERNON PL APT 9A
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:
07106-3136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-416-2128
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2025