Provider First Line Business Practice Location Address: 
201 E COMMERCE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAIRFIELD
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75840-1509
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
903-389-2541
    Provider Business Practice Location Address Fax Number: 
903-389-8939
    Provider Enumeration Date: 
08/29/2013