Provider First Line Business Practice Location Address:
2516 W ILLINOIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75233-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-578-2114
Provider Business Practice Location Address Fax Number:
800-578-1791
Provider Enumeration Date:
12/28/2009