Provider First Line Business Practice Location Address: 
150 W LAKE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HAMLIN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79520-4029
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
325-576-2215
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/27/2006