Provider First Line Business Practice Location Address: 
2843 S. HWY 83
    Provider Second Line Business Practice Location Address: 
C/O MESQUITE LODGE
    Provider Business Practice Location Address City Name: 
CARRIZO SPRINGS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78834
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
855-273-9227
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/12/2014