Provider First Line Business Practice Location Address: 
244 SOUTHWEST PKWY E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
COLLEGE STATION
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77840-4662
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
979-746-3076
    Provider Business Practice Location Address Fax Number: 
979-696-2061
    Provider Enumeration Date: 
01/15/2008