Provider First Line Business Practice Location Address:
110 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH AMBOY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-721-0911
Provider Business Practice Location Address Fax Number:
732-721-0919
Provider Enumeration Date:
12/02/2010