Provider First Line Business Practice Location Address: 
550 NEWARK AVE STE 301B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JERSEY CITY
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07306-1348
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-636-5050
    Provider Business Practice Location Address Fax Number: 
201-604-7979
    Provider Enumeration Date: 
08/19/2011