Provider First Line Business Practice Location Address: 
3601 4TH ST FL 3
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LUBBOCK
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79430-6329
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
817-559-1691
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/25/2022