Provider First Line Business Practice Location Address: 
1100 UPTOWN PARK BLVD
    Provider Second Line Business Practice Location Address: 
#113
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77056-3280
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-877-1720
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/01/2009