Provider First Line Business Practice Location Address:
MARINE CORPS AIR GROUND COMBAT CENTER
Provider Second Line Business Practice Location Address:
BOX 788280
Provider Business Practice Location Address City Name:
29 PALMS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92278-8280
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-830-7054
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/26/2005