Provider First Line Business Practice Location Address: 
1500 E BELT LINE RD
    Provider Second Line Business Practice Location Address: 
SUITE 200
    Provider Business Practice Location Address City Name: 
CARROLLTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75006-6307
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-992-0148
    Provider Business Practice Location Address Fax Number: 
972-243-1400
    Provider Enumeration Date: 
06/12/2006