Provider First Line Business Practice Location Address:
136 SUMMIT AVENUE
Provider Second Line Business Practice Location Address:
RETAIL SPACE #3
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-825-8499
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2025