Provider First Line Business Practice Location Address: 
2817 ROCK MERRITT AVE
    Provider Second Line Business Practice Location Address: 
WOMACK ARMY MEDICAL CENTER
    Provider Business Practice Location Address City Name: 
FORT LIBERTY
    Provider Business Practice Location Address State Name: 
NC
    Provider Business Practice Location Address Postal Code: 
28310
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
910-907-8922
    Provider Business Practice Location Address Fax Number: 
910-907-6069
    Provider Enumeration Date: 
11/24/2009