Provider First Line Business Practice Location Address:
1805 KENTUCKY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79930-1511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-252-7421
Provider Business Practice Location Address Fax Number:
915-521-7021
Provider Enumeration Date:
02/10/2017