Provider First Line Business Practice Location Address: 
717C HIGHWAY 70 E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KINGSTON
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73439-8253
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-564-0549
    Provider Business Practice Location Address Fax Number: 
580-564-1979
    Provider Enumeration Date: 
10/24/2011