Provider First Line Business Practice Location Address: 
415 E MAIN ST
    Provider Second Line Business Practice Location Address: 
BLDG. B
    Provider Business Practice Location Address City Name: 
YUKON
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73099-2259
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
405-350-3000
    Provider Business Practice Location Address Fax Number: 
405-350-8017
    Provider Enumeration Date: 
03/24/2006