Provider First Line Business Practice Location Address: 
30 HOWE AVE
    Provider Second Line Business Practice Location Address: 
SUITE 205
    Provider Business Practice Location Address City Name: 
PASSAIC
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07055-4059
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
718-924-5404
    Provider Business Practice Location Address Fax Number: 
866-452-5954
    Provider Enumeration Date: 
06/04/2013