Provider First Line Business Practice Location Address: 
19600 E ROSS ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TAHLEQUAH
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
74464-0545
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
539-234-3502
    Provider Business Practice Location Address Fax Number: 
539-234-3501
    Provider Enumeration Date: 
09/23/2008