Provider First Line Business Practice Location Address:
20 PROSPECT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 607
Provider Business Practice Location Address City Name:
HACKENSACK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-487-3464
Provider Business Practice Location Address Fax Number:
201-487-0232
Provider Enumeration Date:
11/15/2006