Provider First Line Business Practice Location Address:
268 MLK JR BLVD
Provider Second Line Business Practice Location Address:
3C (CCN)
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-422-1052
Provider Business Practice Location Address Fax Number:
862-237-7298
Provider Enumeration Date:
06/02/2026