Provider First Line Business Practice Location Address: 
1200 14TH ST NW
    Provider Second Line Business Practice Location Address: 
APT 307
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
DC
    Provider Business Practice Location Address Postal Code: 
20005-4133
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
414-530-1381
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/12/2014