Provider First Line Business Practice Location Address:
673 IRVINGTON AVE FL 1
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:
07106-3306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-710-8429
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/11/2025