Provider First Line Business Practice Location Address: 
414 SE 11TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ANADARKO
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73005-4442
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
405-247-9500
    Provider Business Practice Location Address Fax Number: 
405-844-1794
    Provider Enumeration Date: 
06/26/2006