Provider First Line Business Practice Location Address: 
50 HILLCREST MEDICAL BLVD
    Provider Second Line Business Practice Location Address: 
STE 208, 303 & 304
    Provider Business Practice Location Address City Name: 
WACO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76712-8952
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
254-741-1400
    Provider Business Practice Location Address Fax Number: 
254-741-1428
    Provider Enumeration Date: 
05/13/2015