Provider First Line Business Practice Location Address:
13711 12ST ST
Provider Second Line Business Practice Location Address:
BLDG 13815
Provider Business Practice Location Address City Name:
JOINT BASE LEWIS MCCHORD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98498
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-477-5558
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2022