Provider First Line Business Practice Location Address: 
3219 GUADALOUPE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GRAND PRAIRIE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75054-6708
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
469-265-6701
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/04/2011