Provider First Line Business Practice Location Address: 
1504 15TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WELLINGTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79095-3810
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-447-2541
    Provider Business Practice Location Address Fax Number: 
806-447-1264
    Provider Enumeration Date: 
07/18/2005