Provider First Line Business Practice Location Address: 
143 WASHINGTON ST.
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LIMERICK
    Provider Business Practice Location Address State Name: 
ME
    Provider Business Practice Location Address Postal Code: 
04048
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
207-793-4673
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/03/2010