Provider First Line Business Practice Location Address: 
221 E PINE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLDSPRING
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77331-7507
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-622-7232
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/27/2011