Provider First Line Business Practice Location Address: 
6207 19TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LUBBOCK
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79407-1401
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-771-0335
    Provider Business Practice Location Address Fax Number: 
806-209-0111
    Provider Enumeration Date: 
06/09/2006