Provider First Line Business Practice Location Address:
BLDG 170 INNER LOOP ROAD
Provider Second Line Business Practice Location Address:
RM 408B
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-2317
Provider Business Practice Location Address Fax Number:
760-380-5276
Provider Enumeration Date:
10/26/2009