Provider First Line Business Practice Location Address: 
2241 F. M. 984
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ENNIS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75119-0955
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-399-0034
    Provider Business Practice Location Address Fax Number: 
972-646-5278
    Provider Enumeration Date: 
01/03/2006