Provider First Line Business Practice Location Address: 
1253 WALTER ST SE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
DC
    Provider Business Practice Location Address Postal Code: 
20003-1449
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
202-596-5951
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/16/2011