Provider First Line Business Practice Location Address: 
7424 APENNINES DRIVE
    Provider Second Line Business Practice Location Address: 
ARMY SUBSTANCE ABUSE PROGRAM
    Provider Business Practice Location Address City Name: 
FORT RILEY
    Provider Business Practice Location Address State Name: 
KS
    Provider Business Practice Location Address Postal Code: 
66442
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
785-240-6573
    Provider Business Practice Location Address Fax Number: 
785-239-0631
    Provider Enumeration Date: 
02/23/2015