Provider First Line Business Practice Location Address: 
CMR 402 BOX 1551
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
APO
    Provider Business Practice Location Address State Name: 
AE
    Provider Business Practice Location Address Postal Code: 
09180-0016
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
491622733606
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/27/2006