Provider First Line Business Practice Location Address:
5979 35TH ST AND DESERT STORM AVE
Provider Second Line Business Practice Location Address:
FORT CAMPBELL, KY
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AA
Provider Business Practice Location Address Postal Code:
42223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-412-8529
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2026