Provider First Line Business Practice Location Address:
2602 W ILLINOIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75233-1002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-333-9330
Provider Business Practice Location Address Fax Number:
214-333-9325
Provider Enumeration Date:
03/06/2007