Provider First Line Business Practice Location Address: 
1601 W 2ND ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELK CITY
    Provider Business Practice Location Address State Name: 
OK
    Provider Business Practice Location Address Postal Code: 
73644-4427
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
580-225-2700
    Provider Business Practice Location Address Fax Number: 
580-225-2701
    Provider Enumeration Date: 
04/03/2006