Provider First Line Business Practice Location Address: 
134 VINTAGE PARK BLVD STE A15
    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: 
77070-3998
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-272-1743
    Provider Business Practice Location Address Fax Number: 
281-272-1758
    Provider Enumeration Date: 
05/19/2015