Provider First Line Business Practice Location Address:
2250 STANLEY RD
Provider Second Line Business Practice Location Address:
ATTN MCCS-CA, SUITE 276A
Provider Business Practice Location Address City Name:
FORT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-2640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-221-6119
Provider Business Practice Location Address Fax Number:
210-221-8360
Provider Enumeration Date:
05/03/2006