Provider First Line Business Practice Location Address: 
1330 E 8TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ODESSA
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79761-4702
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-550-0990
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/06/2007