Provider First Line Business Practice Location Address:
1900 AVENUE G NW
Provider Second Line Business Practice Location Address:
STE. A
Provider Business Practice Location Address City Name:
CHILDRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79201-3310
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-937-0800
Provider Business Practice Location Address Fax Number:
940-937-0803
Provider Enumeration Date:
06/23/2011