Provider First Line Business Practice Location Address:
4515 PRENTICE ST
Provider Second Line Business Practice Location Address:
SIUTE 203
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75206-5032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-812-9166
Provider Business Practice Location Address Fax Number:
214-812-9251
Provider Enumeration Date:
08/31/2010