Provider First Line Business Practice Location Address:
111 C STREET
Provider Second Line Business Practice Location Address:
BOX 20173
Provider Business Practice Location Address City Name:
CAMP LEJEUNE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28542-0173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-975-5388
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/08/2012