Provider First Line Business Practice Location Address: 
4872 BEECHNUT ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77096-1604
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-535-9173
    Provider Business Practice Location Address Fax Number: 
713-574-6206
    Provider Enumeration Date: 
09/07/2012