Provider First Line Business Practice Location Address: 
210 S ELM ST
    Provider Second Line Business Practice Location Address: 
STE 101
    Provider Business Practice Location Address City Name: 
DENTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76201-6050
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-594-1406
    Provider Business Practice Location Address Fax Number: 
940-293-0688
    Provider Enumeration Date: 
03/27/2012