Provider First Line Business Practice Location Address:
204 5TH ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILDRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79201-4668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-300-1253
Provider Business Practice Location Address Fax Number:
940-937-2517
Provider Enumeration Date:
09/03/2019