Provider First Line Business Practice Location Address:
1397 GEORGE DIETER DR STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79936-7410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-598-8120
Provider Business Practice Location Address Fax Number:
915-598-8121
Provider Enumeration Date:
07/21/2006