Provider First Line Business Practice Location Address:
1610 AVENUE G NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHILDRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79201-0129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-937-3675
Provider Business Practice Location Address Fax Number:
940-937-2327
Provider Enumeration Date:
09/27/2005