Provider First Line Business Practice Location Address:
4432 MALCOLM X BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75215-4349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-928-9180
Provider Business Practice Location Address Fax Number:
214-928-9982
Provider Enumeration Date:
09/28/2006