Provider First Line Business Practice Location Address:
TEL: 973.769.0765 FAX: 954.252.2259
Provider Second Line Business Practice Location Address:
MEMORIAL SYSTEM
Provider Business Practice Location Address City Name:
DEA # FC5079341
Provider Business Practice Location Address State Name:
LIC #: 89636
Provider Business Practice Location Address Postal Code:
NPI 1518538207
Provider Business Practice Location Address Country Code:
UM
Provider Business Practice Location Address Telephone Number:
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/13/2026