Provider First Line Business Practice Location Address: 
1801 S. CARRIER PARKWAY
    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: 
75051-3702
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-262-5272
    Provider Business Practice Location Address Fax Number: 
972-262-1921
    Provider Enumeration Date: 
12/14/2007