Provider First Line Business Practice Location Address: 
1101 FRISCO AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLINTON
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73601-3335
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-323-1978
    Provider Business Practice Location Address Fax Number: 
866-369-2137
    Provider Enumeration Date: 
06/14/2005