Provider First Line Business Practice Location Address: 
2005 KNIGHT LANE BLDG H
    Provider Second Line Business Practice Location Address: 
NAVY MEDICINE SUPPORT COMMAND/ATTN:MEDICALSTAFFSERVICES
    Provider Business Practice Location Address City Name: 
JACKSONVILLE
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32212-0140
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
510-325-6677
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/13/2011