Provider First Line Business Practice Location Address: 
2129 HIGHWAY 146 BYP STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LIBERTY
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77575-6000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
936-641-9341
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/31/2013