Provider First Line Business Practice Location Address: 
2594 MOUNTAIN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SCOTCH PLAINS
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07076-1505
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
908-928-0206
    Provider Business Practice Location Address Fax Number: 
908-928-0206
    Provider Enumeration Date: 
06/20/2011