Provider First Line Business Practice Location Address:
103 S EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KERMIT
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79745-3606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-586-3435
Provider Business Practice Location Address Fax Number:
432-586-6737
Provider Enumeration Date:
10/02/2006