Provider First Line Business Practice Location Address:
4315 28TH STREET
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-792-2104
Provider Business Practice Location Address Fax Number:
806-792-2134
Provider Enumeration Date:
10/17/2006