Provider First Line Business Practice Location Address: 
163 VETERANS DR
    Provider Second Line Business Practice Location Address: 
VA MEDICAL CENTER
    Provider Business Practice Location Address City Name: 
WHITE RIVER JUNCTION
    Provider Business Practice Location Address State Name: 
VT
    Provider Business Practice Location Address Postal Code: 
05009-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
802-295-9363
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/26/2011