Provider First Line Business Practice Location Address:
SHAPE HEALTHCARE FACILITY
Provider Second Line Business Practice Location Address:
UNIT 21414 BOX 116
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09705
Provider Business Practice Location Address Country Code:
BE
Provider Business Practice Location Address Telephone Number:
0113265445801
Provider Business Practice Location Address Fax Number:
0113265445809
Provider Enumeration Date:
09/16/2006