Provider First Line Business Practice Location Address: 
5327 S MCCOLL RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EDINBURG
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78539-9168
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
956-631-2277
    Provider Business Practice Location Address Fax Number: 
956-631-2256
    Provider Enumeration Date: 
06/13/2006