Provider First Line Business Practice Location Address: 
10811 BISSONNET ST
    Provider Second Line Business Practice Location Address: 
D001
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77099-2151
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-291-7172
    Provider Business Practice Location Address Fax Number: 
713-784-2053
    Provider Enumeration Date: 
08/10/2009