Provider First Line Business Practice Location Address: 
12015 LOUETTA RD STE 300
    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: 
77070-1155
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-462-7029
    Provider Business Practice Location Address Fax Number: 
713-462-5252
    Provider Enumeration Date: 
10/17/2008