Provider First Line Business Practice Location Address:
103 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
VERMONT STATE HOSPITAL
Provider Business Practice Location Address City Name:
WATERBURY
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05671-2501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-241-1000
Provider Business Practice Location Address Fax Number:
802-241-1439
Provider Enumeration Date:
01/17/2007