Provider First Line Business Practice Location Address: 
1019 S COLLEGIATE DR
    Provider Second Line Business Practice Location Address: 
SUITE 7
    Provider Business Practice Location Address City Name: 
PARIS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75460-6309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-217-0147
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/28/2011