Provider First Line Business Practice Location Address: 
1217 W INDUSTRIAL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GUTHRIE
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73044-6029
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
405-464-1217
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/28/2011