Provider First Line Business Practice Location Address: 
318 MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FARMINGTON
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06032-2961
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-677-0845
    Provider Business Practice Location Address Fax Number: 
860-430-9752
    Provider Enumeration Date: 
12/01/2006