Provider First Line Business Practice Location Address: 
1801 NORTH LOOP W
    Provider Second Line Business Practice Location Address: 
SUITE 12
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77008-1444
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-868-2908
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
05/05/2006