Provider First Line Business Practice Location Address:
1205 S 19TH ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CORPUS CHRISTI
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78405-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-561-4193
Provider Business Practice Location Address Fax Number:
361-881-8149
Provider Enumeration Date:
08/30/2006