Provider First Line Business Practice Location Address: 
1601 MAIN STREET
    Provider Second Line Business Practice Location Address: 
#602 REHAB SERVICES
    Provider Business Practice Location Address City Name: 
RICHMOND
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77469-3244
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-341-2874
    Provider Business Practice Location Address Fax Number: 
281-341-3012
    Provider Enumeration Date: 
07/07/2008