Provider First Line Business Practice Location Address: 
7707 FANNIN ST STE 195
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77054-1989
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-797-0045
    Provider Business Practice Location Address Fax Number: 
713-797-1821
    Provider Enumeration Date: 
04/30/2018