Provider First Line Business Practice Location Address:
2005 W WALLACE ST
Provider Second Line Business Practice Location Address:
STE. 7
Provider Business Practice Location Address City Name:
SAN SABA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76877-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
325-372-4062
Provider Business Practice Location Address Fax Number:
325-372-6086
Provider Enumeration Date:
10/28/2005