Provider First Line Business Practice Location Address: 
3551 ROGER BROOKE DRIVE
    Provider Second Line Business Practice Location Address: 
BROOKE ARMY MEDICAL CENTER
    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
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-916-8516
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/16/2015