Provider First Line Business Practice Location Address: 
9701 N SAM HOUSTON PKWY E
    Provider Second Line Business Practice Location Address: 
SUITE 150
    Provider Business Practice Location Address City Name: 
HUMBLE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77396-4693
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-973-5237
    Provider Business Practice Location Address Fax Number: 
832-412-2016
    Provider Enumeration Date: 
07/20/2016