Provider First Line Business Practice Location Address: 
4215 FRED WILSON AVE
    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: 
79904-6203
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
915-383-3462
    Provider Business Practice Location Address Fax Number: 
915-975-8184
    Provider Enumeration Date: 
01/31/2015