Provider First Line Business Practice Location Address:
18TH MEDCOM
Provider Second Line Business Practice Location Address:
ATTN: DCCS - QM (CREDENTIALS)
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96205-0054
Provider Business Practice Location Address Country Code:
KR
Provider Business Practice Location Address Telephone Number:
01182279166027
Provider Business Practice Location Address Fax Number:
01182279178110
Provider Enumeration Date:
11/23/2005