Provider First Line Business Practice Location Address: 
191 E. PRICE ROAD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BROWNSVILLE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78521
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-548-7400
    Provider Business Practice Location Address Fax Number: 
956-621-3689
    Provider Enumeration Date: 
08/06/2014