Provider First Line Business Practice Location Address:
3400 W. ILLINOIS
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:
75211-8722
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-339-0347
Provider Business Practice Location Address Fax Number:
214-339-0272
Provider Enumeration Date:
10/31/2006