Provider First Line Business Practice Location Address: 
2207 N SPRING ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AMARILLO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79107-7256
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-437-6273
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/02/2018