Provider First Line Business Practice Location Address: 
1247 HWY 36
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UNION BEACH
    Provider Business Practice Location Address State Name: 
NJ
    Provider Business Practice Location Address Postal Code: 
07735-3519
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
732-619-1656
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/26/2006