Provider First Line Business Practice Location Address: 
1311 BARRE-MONTPELIER RD
    Provider Second Line Business Practice Location Address: 
STE 200
    Provider Business Practice Location Address City Name: 
BERLIN
    Provider Business Practice Location Address State Name: 
VT
    Provider Business Practice Location Address Postal Code: 
05602-0000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
802-371-4239
    Provider Business Practice Location Address Fax Number: 
802-371-5327
    Provider Enumeration Date: 
09/30/2015