Provider First Line Business Practice Location Address: 
430 N MONTE VISTA ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ADA
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
74820-4610
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-332-2323
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/15/2007