Provider First Line Business Practice Location Address: 
627 W. 19TH ST.
    Provider Second Line Business Practice Location Address: 
SUITE 203
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77008-3613
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-248-4636
    Provider Business Practice Location Address Fax Number: 
866-804-7241
    Provider Enumeration Date: 
04/11/2013