Provider First Line Business Practice Location Address:
22 GENESSEE AVE APT 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATERSON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07503-1449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-914-1443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/10/2025