Provider First Line Business Practice Location Address: 
230 CARTER DRIVE
    Provider Second Line Business Practice Location Address: 
BUILDING 718
    Provider Business Practice Location Address City Name: 
FORT SHAFTER
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96858
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-787-4930
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/26/2006