Provider First Line Business Practice Location Address:
170 GOVERNORS AVE
Provider Second Line Business Practice Location Address:
LAWRENCE MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02155-1643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-306-6264
Provider Business Practice Location Address Fax Number:
781-306-6267
Provider Enumeration Date:
11/14/2005