Provider First Line Business Practice Location Address:
1 S PROSPECT ST
Provider Second Line Business Practice Location Address:
FAHC ST. JOSEPH'S 5TH FLOOR, UHC CAMPUS
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05401-3456
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-847-4576
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2006