Provider First Line Business Practice Location Address:
1148 CLINTON AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRVINGTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
301-458-0890
Provider Business Practice Location Address Fax Number:
443-541-4748
Provider Enumeration Date:
09/05/2020