Provider First Line Business Practice Location Address:
4640 N LOOP 289
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:
79416-2423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-761-4880
Provider Business Practice Location Address Fax Number:
806-749-5944
Provider Enumeration Date:
06/15/2005