Provider First Line Business Practice Location Address:
144 THADEUS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-6259
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-885-8686
Provider Business Practice Location Address Fax Number:
207-883-7154
Provider Enumeration Date:
10/17/2005