Provider First Line Business Practice Location Address: 
9644 COURT GLEN DR
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77099-2541
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-530-3400
    Provider Business Practice Location Address Fax Number: 
281-530-3603
    Provider Enumeration Date: 
07/11/2012