Provider First Line Business Practice Location Address: 
1215 LEE ST
    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: 
22908-0816
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
434-243-4288
    Provider Business Practice Location Address Fax Number: 
434-243-7310
    Provider Enumeration Date: 
06/13/2006