Provider First Line Business Practice Location Address: 
349 2ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07302-2669
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-396-0145
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/16/2006