Provider First Line Business Practice Location Address: 
660 CLINTON AVE
    Provider Second Line Business Practice Location Address: 
#680
    Provider Business Practice Location Address City Name: 
NEWARK
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07108-1432
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
973-371-4985
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/30/2006