Provider First Line Business Practice Location Address:
T-27 N. LEWIS AVE.
Provider Second Line Business Practice Location Address:
USA MEDDAC
Provider Business Practice Location Address City Name:
FORT DRUM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13602-5004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-772-9947
Provider Business Practice Location Address Fax Number:
315-772-9929
Provider Enumeration Date:
05/03/2006