Provider First Line Business Practice Location Address: 
1010 SOUTH 4TH STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CANADIAN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79014
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-323-8882
    Provider Business Practice Location Address Fax Number: 
806-323-6108
    Provider Enumeration Date: 
03/30/2015