Provider First Line Business Practice Location Address: 
1001 S HIGHWAY 67
    Provider Second Line Business Practice Location Address: 
H & I
    Provider Business Practice Location Address City Name: 
CEDAR HILL
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75104-3102
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-291-8293
    Provider Business Practice Location Address Fax Number: 
972-291-8290
    Provider Enumeration Date: 
09/25/2009