Provider First Line Business Practice Location Address: 
716 LEVY AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CHARLOTTESVILLE
    Provider Business Practice Location Address State Name: 
VA
    Provider Business Practice Location Address Postal Code: 
22902-5730
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
703-625-1027
    Provider Business Practice Location Address Fax Number: 
800-923-4303
    Provider Enumeration Date: 
11/13/2007