Provider First Line Business Practice Location Address:
418 PROSPECT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07017-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
862-459-4478
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2026