Provider First Line Business Practice Location Address:
1599 CHOCTAW LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT CAMPBELL
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42223-1043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-798-8041
Provider Business Practice Location Address Fax Number:
270-798-8838
Provider Enumeration Date:
01/16/2006