Provider First Line Business Practice Location Address: 
60 W RIDGEWOOD AVE
    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: 
07450-3197
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
973-208-0085
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/08/2007