Provider First Line Business Practice Location Address: 
13800 MONTFORT DR
    Provider Second Line Business Practice Location Address: 
STE 260
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75240-4348
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-661-5444
    Provider Business Practice Location Address Fax Number: 
855-858-5444
    Provider Enumeration Date: 
03/27/2012