Provider First Line Business Practice Location Address:
BLDG 166 4TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FT. 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:
760-380-6862
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2006