Provider First Line Business Practice Location Address:
2526 22ND ST
Provider Second Line Business Practice Location Address:
ROOM 136
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-5507
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-956-4566
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2011