Provider First Line Business Practice Location Address: 
6624 FANNIN ST STE 2480
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77030-2309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-529-5530
    Provider Business Practice Location Address Fax Number: 
713-791-1786
    Provider Enumeration Date: 
03/31/2016