Provider First Line Business Practice Location Address: 
2809 TANNER WAY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GRAND PRAIRIE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75052-4239
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
469-767-6306
    Provider Business Practice Location Address Fax Number: 
972-641-7556
    Provider Enumeration Date: 
02/12/2007