Provider First Line Business Practice Location Address: 
18220 FM 1431
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
JONESTOWN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78645-4042
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
877-800-5722
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/07/2005