Provider First Line Business Practice Location Address: 
800 W CENTRAL TEXAS EXPY STE 370
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HARKER HEIGHTS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76548-3201
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
254-618-4320
    Provider Business Practice Location Address Fax Number: 
254-618-4325
    Provider Enumeration Date: 
10/16/2011