Provider First Line Business Practice Location Address: 
1631 N LOOP WEST
    Provider Second Line Business Practice Location Address: 
SUITE 245
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77008-1528
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-486-8150
    Provider Business Practice Location Address Fax Number: 
713-486-8155
    Provider Enumeration Date: 
08/13/2009