Provider First Line Business Practice Location Address:
916 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:
75224-1754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-941-7611
Provider Business Practice Location Address Fax Number:
214-941-7818
Provider Enumeration Date:
03/17/2009