Provider First Line Business Practice Location Address: 
4104 SW 33RD AVE
    Provider Second Line Business Practice Location Address: 
200
    Provider Business Practice Location Address City Name: 
AMARILLO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79109-1203
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-803-9671
    Provider Business Practice Location Address Fax Number: 
806-803-9674
    Provider Enumeration Date: 
07/07/2016