Provider First Line Business Practice Location Address: 
9757 WHITE ROCK TRL
    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: 
75238-1805
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-553-5553
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/19/2013