Provider First Line Business Practice Location Address: 
389 COUNTY ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NEW BEDFORD
    Provider Business Practice Location Address State Name: 
MA
    Provider Business Practice Location Address Postal Code: 
02740-4995
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
508-997-1570
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/31/2007