Provider First Line Business Practice Location Address: 
221 N. KANSAS SUITE 700
    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: 
79901
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
915-496-3083
    Provider Business Practice Location Address Fax Number: 
866-880-9207
    Provider Enumeration Date: 
04/12/2018