Provider First Line Business Practice Location Address:
123 MEDICAL DR
Provider Second Line Business Practice Location Address:
B
Provider Business Practice Location Address City Name:
PALESTINE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75801-8508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-729-8616
Provider Business Practice Location Address Fax Number:
903-729-8618
Provider Enumeration Date:
08/16/2005