Provider First Line Business Practice Location Address: 
12407 NORTH MOPAC EXWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
AUSTIN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78758
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
512-339-6644
    Provider Business Practice Location Address Fax Number: 
512-832-9128
    Provider Enumeration Date: 
08/30/2006