Provider First Line Business Practice Location Address: 
13114 FM 1960 RD W STE 119
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77065-5590
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-487-8233
    Provider Business Practice Location Address Fax Number: 
713-583-9004
    Provider Enumeration Date: 
07/18/2012