Provider First Line Business Practice Location Address: 
16-00 STATE HWY 208
    Provider Second Line Business Practice Location Address: 
LL3
    Provider Business Practice Location Address City Name: 
FAIR LAWN
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07410-5419
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
201-791-5000
    Provider Business Practice Location Address Fax Number: 
201-791-5000
    Provider Enumeration Date: 
10/04/2006