Provider First Line Business Practice Location Address:
4293 RT 47
Provider Second Line Business Practice Location Address:
MEDICAL DEPT BAYSIDE STATE PRISON
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-785-9370
Provider Business Practice Location Address Fax Number:
856-785-9262
Provider Enumeration Date:
08/23/2007