Provider First Line Business Practice Location Address:
400 RESERVOIR AVE
Provider Second Line Business Practice Location Address:
SUITE 1D COASTAL MEDICAL
Provider Business Practice Location Address City Name:
PROVIDENCE
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02907-3565
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-781-2400
Provider Business Practice Location Address Fax Number:
401-781-2687
Provider Enumeration Date:
08/23/2005