Provider First Line Business Practice Location Address: 
3324 S GEORGIA ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AMARILLO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79109-3446
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-352-2711
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/21/2007