Provider First Line Business Practice Location Address:
4TH AND INNER LOOP ROAD
Provider Second Line Business Practice Location Address:
BLDG 171
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-526-5537
Provider Business Practice Location Address Fax Number:
719-524-2843
Provider Enumeration Date:
03/17/2020