Provider First Line Business Practice Location Address: 
800 S PINE STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
KOUNTZE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77625
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
409-246-3492
    Provider Business Practice Location Address Fax Number: 
409-246-8192
    Provider Enumeration Date: 
08/20/2006