Provider First Line Business Practice Location Address:
1139 E JERSEY ST
Provider Second Line Business Practice Location Address:
SUITE 504
Provider Business Practice Location Address City Name:
ELIZABETH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07201-2473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-900-0014
Provider Business Practice Location Address Fax Number:
732-960-8607
Provider Enumeration Date:
03/11/2010