Provider First Line Business Practice Location Address:
1344 BACKUS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL PASO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79925-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
915-319-5472
Provider Business Practice Location Address Fax Number:
915-860-4186
Provider Enumeration Date:
02/03/2016