Provider First Line Business Practice Location Address: 
3D MARDIV DET
    Provider Second Line Business Practice Location Address: 
REGIMENTAL AID STATION
    Provider Business Practice Location Address City Name: 
M C B H KANEOHE BAY
    Provider Business Practice Location Address State Name: 
HI
    Provider Business Practice Location Address Postal Code: 
96863
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
808-343-7780
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/21/2009