Provider First Line Business Practice Location Address:
615 S 19TH ST
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:
07103-1116
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-964-4720
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2026