Provider First Line Business Practice Location Address: 
20 YORK STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW HAVEN
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06504
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
203-688-2046
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/11/2007