Provider First Line Business Practice Location Address: 
7760 FM 4
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
JACKSBORO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76458-3622
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-567-3856
    Provider Business Practice Location Address Fax Number: 
940-567-5256
    Provider Enumeration Date: 
02/16/2007