Provider First Line Business Practice Location Address: 
7979 W VIRGINIA DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75237-3798
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-780-8400
    Provider Business Practice Location Address Fax Number: 
972-656-0380
    Provider Enumeration Date: 
03/20/2015