Provider First Line Business Practice Location Address: 
10935 ESTATE LANE
    Provider Second Line Business Practice Location Address: 
SUITE 190
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75238
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-226-1015
    Provider Business Practice Location Address Fax Number: 
972-226-1814
    Provider Enumeration Date: 
06/15/2006