Provider First Line Business Practice Location Address: 
471 CENTER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PHILLIPSBURG
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
08865-2665
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
908-454-7440
    Provider Business Practice Location Address Fax Number: 
908-454-9050
    Provider Enumeration Date: 
07/19/2006