Provider First Line Business Practice Location Address: 
1001 JAMES ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WESLACO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78596-0008
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-647-8600
    Provider Business Practice Location Address Fax Number: 
956-969-9564
    Provider Enumeration Date: 
11/09/2006