Provider First Line Business Practice Location Address:
591 SUMMIT AVE. STORE #1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-217-0092
Provider Business Practice Location Address Fax Number:
201-217-0093
Provider Enumeration Date:
02/10/2009