Provider First Line Business Practice Location Address: 
4323 SAN FELIPE ST
    Provider Second Line Business Practice Location Address: 
T-0955
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77027-3406
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-331-0166
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/26/2011