Provider First Line Business Practice Location Address:
14-30 PROSPECT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR LAWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07410-5330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-209-1427
Provider Business Practice Location Address Fax Number:
323-372-0306
Provider Enumeration Date:
01/07/2026