Provider First Line Business Practice Location Address: 
19 E 27TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BAYONNE
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07002-4608
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-339-6111
    Provider Business Practice Location Address Fax Number: 
201-339-6333
    Provider Enumeration Date: 
03/18/2011