Provider First Line Business Practice Location Address: 
551 N STEMMONS ST
    Provider Second Line Business Practice Location Address: 
SUITE100
    Provider Business Practice Location Address City Name: 
SANGER
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76266-9307
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-458-9000
    Provider Business Practice Location Address Fax Number: 
940-458-9001
    Provider Enumeration Date: 
11/03/2006