Provider First Line Business Practice Location Address: 
396 LAFAYETTE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEWARK
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07105-2704
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
973-690-5306
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/26/2007