Provider First Line Business Practice Location Address:
269 VASSAR 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:
07112-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-858-4476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/29/2025