Provider First Line Business Practice Location Address: 
1000 LAFAYETTE BLVD FL 11
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRIDGEPORT
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06604-4725
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
203-464-3638
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/12/2016