Provider First Line Business Practice Location Address: 
6030 W UNIVERSITY BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ODESSA
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79764-8530
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
432-640-6600
    Provider Business Practice Location Address Fax Number: 
432-640-4791
    Provider Enumeration Date: 
04/19/2016