Provider First Line Business Practice Location Address:
3RD STREET & INNER LOOP ROAD
Provider Second Line Business Practice Location Address:
BUILDING 166, ROOM 414
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310-5109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-5388
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/27/2011