Provider First Line Business Practice Location Address: 
1015 EAST 32ND ST
    Provider Second Line Business Practice Location Address: 
SUITE 101
    Provider Business Practice Location Address City Name: 
AUSTIN
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78705
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
512-477-6341
    Provider Business Practice Location Address Fax Number: 
512-477-1148
    Provider Enumeration Date: 
05/24/2005