Provider First Line Business Practice Location Address:
221 3RD ST W
Provider Second Line Business Practice Location Address:
12TH MEDICAL GROUP
Provider Business Practice Location Address City Name:
RANDOLPH A F B
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78150-4800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-652-1846
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/03/2005