Provider First Line Business Practice Location Address:
59 MHS/SGOWV1, 2200 BERGQUIST DR STE 1
Provider Second Line Business Practice Location Address:
WHMC/PSYCHIATRY
Provider Business Practice Location Address City Name:
LACKLAND AFB
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78236-9908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-292-5941
Provider Business Practice Location Address Fax Number:
210-292-5944
Provider Enumeration Date:
04/19/2010