Provider First Line Business Practice Location Address: 
12 GRAVES AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LYNN
    Provider Business Practice Location Address State Name: 
MA
    Provider Business Practice Location Address Postal Code: 
01902-2604
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
781-913-6461
    Provider Business Practice Location Address Fax Number: 
781-780-7297
    Provider Enumeration Date: 
02/15/2011