Provider First Line Business Practice Location Address: 
98 WASHINGTON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MIDDLETOWN
    Provider Business Practice Location Address State Name: 
CT
    Provider Business Practice Location Address Postal Code: 
06457-2803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
860-346-0771
    Provider Business Practice Location Address Fax Number: 
860-346-0772
    Provider Enumeration Date: 
09/30/2014