Provider First Line Business Practice Location Address: 
142 CEDAR HILL AVE # 2L
    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: 
06511-2708
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
203-361-6381
    Provider Business Practice Location Address Fax Number: 
203-498-7670
    Provider Enumeration Date: 
10/31/2016