Provider First Line Business Practice Location Address: 
5514 ATASCOCITA RD
    Provider Second Line Business Practice Location Address: 
#100
    Provider Business Practice Location Address City Name: 
HUMBLE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77346-2968
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-548-2020
    Provider Business Practice Location Address Fax Number: 
281-540-1287
    Provider Enumeration Date: 
12/10/2014