Provider First Line Business Practice Location Address: 
47 PLEASANT STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PASSADUMKEAG
    Provider Business Practice Location Address State Name: 
ME
    Provider Business Practice Location Address Postal Code: 
04475-0004
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
207-732-5513
    Provider Business Practice Location Address Fax Number: 
207-794-6777
    Provider Enumeration Date: 
09/12/2006