Provider First Line Business Practice Location Address: 
1040 W JEFFERSON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
BROWNSVILLE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78520-6338
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-698-5493
    Provider Business Practice Location Address Fax Number: 
956-698-4423
    Provider Enumeration Date: 
05/09/2006