Provider First Line Business Practice Location Address: 
2139 GEORGIA AVE NW
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
DC
    Provider Business Practice Location Address Postal Code: 
20059-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
202-806-7540
    Provider Business Practice Location Address Fax Number: 
202-332-8576
    Provider Enumeration Date: 
05/21/2007