Provider First Line Business Practice Location Address:
8308 COUNTY ROAD 3240
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDALOU
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79329-6012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-617-1213
Provider Business Practice Location Address Fax Number:
800-617-1214
Provider Enumeration Date:
12/22/2005