Provider First Line Business Practice Location Address: 
489 STATE STREET
    Provider Second Line Business Practice Location Address: 
EMMC
    Provider Business Practice Location Address City Name: 
BANGOR
    Provider Business Practice Location Address State Name: 
ME
    Provider Business Practice Location Address Postal Code: 
04401-6616
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
207-973-7000
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/08/2010