Provider First Line Business Practice Location Address:
705 HENRY BARBER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT LAVACA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77979-5743
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-552-1140
Provider Business Practice Location Address Fax Number:
800-353-2196
Provider Enumeration Date:
09/20/2006