Provider First Line Business Practice Location Address:
17TH AND C ST.
Provider Second Line Business Practice Location Address:
BLDG. 11582
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:
253-966-1991
Provider Business Practice Location Address Fax Number:
253-967-2639
Provider Enumeration Date:
08/17/2006