Provider First Line Business Practice Location Address: 
BUILDING M7-0355
    Provider Second Line Business Practice Location Address: 
ROOM 1116B
    Provider Business Practice Location Address City Name: 
KENNEDY SPACE CENTER
    Provider Business Practice Location Address State Name: 
FL
    Provider Business Practice Location Address Postal Code: 
32899
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
321-867-6385
    Provider Business Practice Location Address Fax Number: 
321-867-3881
    Provider Enumeration Date: 
03/21/2013