Provider First Line Business Practice Location Address: 
546 N KEGLEY RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TEMPLE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76502-4069
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
254-215-0888
    Provider Business Practice Location Address Fax Number: 
254-724-1667
    Provider Enumeration Date: 
11/30/2006