Provider First Line Business Practice Location Address: 
7200 SW 45TH AVE UNIT 11
    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: 
79109-5084
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-373-0986
    Provider Business Practice Location Address Fax Number: 
806-373-5128
    Provider Enumeration Date: 
01/18/2008