Provider First Line Business Practice Location Address: 
39 WESTERN AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOUTH PARIS
    Provider Business Practice Location Address State Name: 
ME
    Provider Business Practice Location Address Postal Code: 
04281-1412
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
207-890-5868
    Provider Business Practice Location Address Fax Number: 
207-743-1614
    Provider Enumeration Date: 
12/22/2014