Provider First Line Business Practice Location Address: 
276 PASSAIC AVE UNIT A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KEARNY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07032-1129
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-719-9371
    Provider Business Practice Location Address Fax Number: 
201-719-9406
    Provider Enumeration Date: 
04/12/2018