Provider First Line Business Practice Location Address:
3551 ROGER BROOKE DR
Provider Second Line Business Practice Location Address:
BROOKE ARMY MEDICAL CENTER, MCHE-QD (CREDENTIALING)
Provider Business Practice Location Address City Name:
JBSA FT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-4504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-916-1455
Provider Business Practice Location Address Fax Number:
210-916-3585
Provider Enumeration Date:
08/01/2006