Provider First Line Business Practice Location Address: 
6 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW MILFORD
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06776-2802
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
845-629-8529
    Provider Business Practice Location Address Fax Number: 
845-832-7082
    Provider Enumeration Date: 
09/28/2011