Provider First Line Business Practice Location Address: 
11101 US 380
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CROSSROADS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76227
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-365-5762
    Provider Business Practice Location Address Fax Number: 
940-686-5834
    Provider Enumeration Date: 
06/01/2011