Provider First Line Business Practice Location Address:
1311 N WASHINGTON 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:
75204-6501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-824-2563
Provider Business Practice Location Address Fax Number:
214-824-3353
Provider Enumeration Date:
06/23/2005