Provider First Line Business Practice Location Address:
100 INDEPENDENCE DR
Provider Second Line Business Practice Location Address:
MEDICAL AID STATION, BLDG 418
Provider Business Practice Location Address City Name:
CAMP DOUGLAS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54618-5001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-427-1214
Provider Business Practice Location Address Fax Number:
608-427-1225
Provider Enumeration Date:
05/05/2009