Provider First Line Business Practice Location Address: 
7121 S PADRE ISLAND DR
    Provider Second Line Business Practice Location Address: 
303
    Provider Business Practice Location Address City Name: 
CORPUS CHRISTI
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78412-4938
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
361-980-1244
    Provider Business Practice Location Address Fax Number: 
361-980-1248
    Provider Enumeration Date: 
09/03/2009