Provider First Line Business Practice Location Address: 
43 SMITH RD
    Provider Second Line Business Practice Location Address: 
NAVAL HEALTH CARE NEW ENGLAND NEWPORT
    Provider Business Practice Location Address City Name: 
NEWPORT
    Provider Business Practice Location Address State Name: 
RI
    Provider Business Practice Location Address Postal Code: 
02841-1002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-694-2377
    Provider Business Practice Location Address Fax Number: 
860-694-3590
    Provider Enumeration Date: 
02/06/2006