Provider First Line Business Practice Location Address: 
1391 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WILLIMANTIC
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06226-1949
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-456-7240
    Provider Business Practice Location Address Fax Number: 
860-423-0219
    Provider Enumeration Date: 
07/07/2006