Provider First Line Business Practice Location Address:
650 JOEL DR
Provider Second Line Business Practice Location Address:
BLANCHFIELD ACH, CREDENTIALING OFFICE - ROOM 1EB01
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-412-8983
Provider Business Practice Location Address Fax Number:
270-461-0243
Provider Enumeration Date:
04/01/2014