Provider First Line Business Practice Location Address:
566 MT PROSPECT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07104-1530
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-485-5334
Provider Business Practice Location Address Fax Number:
973-484-9561
Provider Enumeration Date:
01/16/2007