Provider First Line Business Practice Location Address: 
3201 N WARE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MCALLEN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78501-3305
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-563-7518
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/29/2014