Provider First Line Business Practice Location Address: 
CMR 442 BOX 33
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
APO
    Provider Business Practice Location Address State Name: 
AE
    Provider Business Practice Location Address Postal Code: 
09042
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
493221172201
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/25/2006