Provider First Line Business Practice Location Address: 
99 FARMINGTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRISTOL
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06010-4226
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-583-3373
    Provider Business Practice Location Address Fax Number: 
860-583-0248
    Provider Enumeration Date: 
03/15/2008