Provider First Line Business Practice Location Address: 
880 PROSPECTOR TRL
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
HARKER HEIGHTS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76548-2700
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
254-690-1512
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/17/2015