Provider First Line Business Practice Location Address:
28 CLARK STREET
Provider Second Line Business Practice Location Address:
BAY STATE CORRECTIONAL CENTER
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
508-668-1687
Provider Business Practice Location Address Fax Number:
508-660-1019
Provider Enumeration Date:
10/03/2006