Provider First Line Business Practice Location Address: 
3828 HUGHES CT
    Provider Second Line Business Practice Location Address: 
STE 104
    Provider Business Practice Location Address City Name: 
DICKINSON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77539-6244
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-534-2576
    Provider Business Practice Location Address Fax Number: 
281-534-4598
    Provider Enumeration Date: 
05/15/2006