Provider First Line Business Practice Location Address:
845 NEWARK AVENUE
Provider Second Line Business Practice Location Address:
UNIT 1
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07306-5195
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-513-1256
Provider Business Practice Location Address Fax Number:
877-624-7856
Provider Enumeration Date:
11/20/2025