Provider First Line Business Practice Location Address: 
3234 64TH ST STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LUBBOCK
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79413-5761
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
806-793-0651
    Provider Business Practice Location Address Fax Number: 
806-793-1338
    Provider Enumeration Date: 
08/18/2022