Provider First Line Business Practice Location Address:
119 PROSPECT ST STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIDGEWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07450-4451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-444-1185
Provider Business Practice Location Address Fax Number:
201-444-1403
Provider Enumeration Date:
06/17/2005