Provider First Line Business Practice Location Address:
199 LAFAYETTE AVENUE
Provider Second Line Business Practice Location Address:
2I
Provider Business Practice Location Address City Name:
PASSAIC
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07055-4782
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-208-0814
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2010