Provider First Line Business Practice Location Address: 
1650 COCHRANE CIR
    Provider Second Line Business Practice Location Address: 
BEHAVIORAL HEALTH
    Provider Business Practice Location Address City Name: 
FORT CARSON
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80913-4603
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
719-576-9890
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/12/2006