Provider First Line Business Practice Location Address: 
2405 N ED CAREY DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HARLINGEN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78550-8221
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-425-8558
    Provider Business Practice Location Address Fax Number: 
956-425-8838
    Provider Enumeration Date: 
08/29/2022