Provider First Line Business Practice Location Address: 
152 MARKET ST
    Provider Second Line Business Practice Location Address: 
SUITE 217
    Provider Business Practice Location Address City Name: 
PATERSON
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07505-1724
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
973-980-5013
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/07/2012