Provider First Line Business Practice Location Address:
ATTN: I MEF CREDENTIALING (RM 4172)
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMP PENDLETON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92055-5191
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-324-5308
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/22/2022