Provider First Line Business Practice Location Address: 
9550 FOREST LN STE 605
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75243-6179
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-880-8541
    Provider Business Practice Location Address Fax Number: 
214-221-1440
    Provider Enumeration Date: 
01/05/2006