Provider First Line Business Practice Location Address: 
128 N MAIN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAINT ALBANS
    Provider Business Practice Location Address State Name: 
VT
    Provider Business Practice Location Address Postal Code: 
05478-1551
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
802-527-2225
    Provider Business Practice Location Address Fax Number: 
802-527-2013
    Provider Enumeration Date: 
02/28/2007