Provider First Line Business Practice Location Address: 
WRAMC BLDG 2 RM 2G01
    Provider Second Line Business Practice Location Address: 
6900 GEORGIA AVE. NW
    Provider Business Practice Location Address City Name: 
WASHINGTON
    Provider Business Practice Location Address State Name: 
DC
    Provider Business Practice Location Address Postal Code: 
20307-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
202-356-1012
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/18/2011