Provider First Line Business Practice Location Address: 
313 SOUTH AVE
    Provider Second Line Business Practice Location Address: 
SUITE #205 PANTHER PT AND SPORTS MEDICINE
    Provider Business Practice Location Address City Name: 
FANWOOD
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07023
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
908-889-7900
    Provider Business Practice Location Address Fax Number: 
908-889-6003
    Provider Enumeration Date: 
10/17/2006