Provider First Line Business Practice Location Address: 
1413 S LOWRY LN
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ATOKA
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
74525-3639
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-239-0583
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/03/2013