Provider First Line Business Practice Location Address: 
125 ELM STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BENNINGTON
    Provider Business Practice Location Address State Name: 
VT
    Provider Business Practice Location Address Postal Code: 
05201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
802-442-9533
    Provider Business Practice Location Address Fax Number: 
802-442-2004
    Provider Enumeration Date: 
10/25/2006