Provider First Line Business Practice Location Address:
26 LAKESIDE RD
Provider Second Line Business Practice Location Address:
LAKESIDE COMMUNITY RESIDENCE
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08873
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-564-0500
Provider Business Practice Location Address Fax Number:
732-564-0501
Provider Enumeration Date:
06/19/2015