Provider First Line Business Practice Location Address: 
8000 DENTON HWY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WATAUGA
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76148-2464
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
817-427-1099
    Provider Business Practice Location Address Fax Number: 
817-427-1099
    Provider Enumeration Date: 
07/24/2006