Provider First Line Business Practice Location Address:
EASTERN STATE HOSPITAL 4601 IRONBOUND RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23187-8791
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-253-7434
Provider Business Practice Location Address Fax Number:
757-253-4564
Provider Enumeration Date:
11/19/2005