Provider First Line Business Practice Location Address: 
2305 N ED CAREY DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HARLINGEN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78550-8219
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-230-1210
    Provider Business Practice Location Address Fax Number: 
956-412-0304
    Provider Enumeration Date: 
06/27/2011