Provider First Line Business Practice Location Address: 
703 E. 9TH STREET N.
    Provider Second Line Business Practice Location Address: 
BLDG 4970 RM 221
    Provider Business Practice Location Address City Name: 
FORT STEWART
    Provider Business Practice Location Address State Name: 
GA
    Provider Business Practice Location Address Postal Code: 
31314
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
912-425-1391
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/09/2014