Provider First Line Business Practice Location Address: 
3537 S INTERSTATE 35 E
    Provider Second Line Business Practice Location Address: 
SUITE 320
    Provider Business Practice Location Address City Name: 
DENTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76210-6800
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-383-1581
    Provider Business Practice Location Address Fax Number: 
940-383-4627
    Provider Enumeration Date: 
11/14/2006