Provider First Line Business Practice Location Address:
655 W ILLINOIS AVE
Provider Second Line Business Practice Location Address:
WYNNEWOOD VILLAGE SHP CTR STE 740
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75224-1814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-943-7065
Provider Business Practice Location Address Fax Number:
214-943-8152
Provider Enumeration Date:
09/01/2006