Provider First Line Business Practice Location Address:
NHCP
Provider Second Line Business Practice Location Address:
BOX 555191
Provider Business Practice Location Address City Name:
CAMP PENDLETON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92055-5191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-725-2178
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/28/2012