Provider First Line Business Practice Location Address: 
NATIONAL NAVAL MEDICAL CTR
    Provider Second Line Business Practice Location Address: 
8901 WISCONSIN AVE
    Provider Business Practice Location Address City Name: 
BETHESDA
    Provider Business Practice Location Address State Name: 
MD
    Provider Business Practice Location Address Postal Code: 
20889-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
301-402-3190
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/24/2006