Provider First Line Business Practice Location Address:
1112 HALF LEAGUE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT LAVACA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-552-6916
Provider Business Practice Location Address Fax Number:
361-552-6916
Provider Enumeration Date:
03/03/2009