Provider First Line Business Practice Location Address: 
4505 HIGHWAY 6 N
    Provider Second Line Business Practice Location Address: 
SUITE 400-D
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77084-3495
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-683-4472
    Provider Business Practice Location Address Fax Number: 
832-436-1810
    Provider Enumeration Date: 
05/21/2013