Provider First Line Business Practice Location Address: 
215 DANIELS AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BRIDGEPORT
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06606-1513
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-558-9143
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/10/2014