Provider First Line Business Practice Location Address: 
433 S TANCAHUA ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CORPUS CHRISTI
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78401-3422
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
361-882-1717
    Provider Business Practice Location Address Fax Number: 
361-288-8555
    Provider Enumeration Date: 
12/29/2014