Provider First Line Business Practice Location Address: 
1 N MILTON ST
    Provider Second Line Business Practice Location Address: 
SUITE 10
    Provider Business Practice Location Address City Name: 
SAN ANGELO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76901-3261
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
325-659-5020
    Provider Business Practice Location Address Fax Number: 
325-659-5024
    Provider Enumeration Date: 
11/07/2006