Provider First Line Business Practice Location Address:
319 S FIRST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IMPERIAL
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-536-2410
Provider Business Practice Location Address Fax Number:
915-536-2258
Provider Enumeration Date:
11/21/2005