Provider First Line Business Practice Location Address:
128 CHAFFEE RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT BLISS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79906-3811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-568-5001
Provider Business Practice Location Address Fax Number:
915-568-5174
Provider Enumeration Date:
12/13/2005