Provider First Line Business Practice Location Address:
102 E KING AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78384-1838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
361-279-8804
Provider Business Practice Location Address Fax Number:
361-279-8812
Provider Enumeration Date:
08/16/2006