Provider First Line Business Practice Location Address: 
528 N MAIN ST
    Provider Second Line Business Practice Location Address: 
SUITE 3
    Provider Business Practice Location Address City Name: 
PROVIDENCE
    Provider Business Practice Location Address State Name: 
RI
    Provider Business Practice Location Address Postal Code: 
02904-5762
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
401-421-3306
    Provider Business Practice Location Address Fax Number: 
401-421-3307
    Provider Enumeration Date: 
10/21/2005