Provider First Line Business Practice Location Address:
1215 S COULTER ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
AMARILLO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79106-1758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-350-7355
Provider Business Practice Location Address Fax Number:
806-350-7362
Provider Enumeration Date:
09/07/2005