Provider First Line Business Practice Location Address: 
BUILDING 3508, DARNALL LOOP
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT HOOD
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76544
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-432-4169
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/19/2011