Provider First Line Business Practice Location Address: 
924 BERGEN AVE
    Provider Second Line Business Practice Location Address: 
#209
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07306-3018
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
646-525-9538
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/31/2015