Provider First Line Business Practice Location Address:
BUILDING 2140, LIGGETT AVENUE
Provider Second Line Business Practice Location Address:
ROOM 2050
Provider Business Practice Location Address City Name:
FORT LEWIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-967-5822
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2007