Provider First Line Business Practice Location Address:
30 PROSPECT AVE
Provider Second Line Business Practice Location Address:
FACULTY PRACTICE OFFICE
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
551-996-5045
Provider Business Practice Location Address Fax Number:
201-343-9823
Provider Enumeration Date:
05/17/2006