Provider First Line Business Practice Location Address:
106 1/2 N BROADWAY
Provider Second Line Business Practice Location Address:
BOX 98
Provider Business Practice Location Address City Name:
SOUTH AMBOY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08879-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-721-0028
Provider Business Practice Location Address Fax Number:
732-721-0008
Provider Enumeration Date:
03/18/2006