Provider First Line Business Practice Location Address:
9040 REID ST # A
Provider Second Line Business Practice Location Address:
ATTN: CREDENTIALS)
Provider Business Practice Location Address City Name:
JOINT BASE LEWIS MCCHORD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-5037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-1250
Provider Business Practice Location Address Fax Number:
253-968-2550
Provider Enumeration Date:
10/17/2006