Provider First Line Business Practice Location Address:
BLDG 478, 4TH STREET & G AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT IRWIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92310-5076
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-380-5733
Provider Business Practice Location Address Fax Number:
760-380-5733
Provider Enumeration Date:
09/06/2006