Provider First Line Business Practice Location Address: 
2190 EASTEX FREEWAY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BEAUMONT
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77703
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
409-832-0999
    Provider Business Practice Location Address Fax Number: 
409-832-0993
    Provider Enumeration Date: 
01/14/2008