Provider First Line Business Practice Location Address:
164 SUMMITT AVE, ROOM C70
Provider Second Line Business Practice Location Address:
THE MIRIAM HOSPITAL
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-793-3922
Provider Business Practice Location Address Fax Number:
401-435-7069
Provider Enumeration Date:
06/15/2006