Provider First Line Business Practice Location Address: 
5605 RICHMOND AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75206-7113
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-824-2501
    Provider Business Practice Location Address Fax Number: 
214-887-8659
    Provider Enumeration Date: 
07/24/2006