Provider First Line Business Practice Location Address: 
5234 JARMAN ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ABILENE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79601-7002
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
325-677-1731
    Provider Business Practice Location Address Fax Number: 
325-794-1416
    Provider Enumeration Date: 
03/30/2016