Provider First Line Business Practice Location Address:
BLDG 11582 17TH AND C STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH FORT LEWIS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-966-1991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007