Provider First Line Business Practice Location Address: 
2200 DENNISON ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75212-2460
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-502-4047
    Provider Business Practice Location Address Fax Number: 
214-266-2296
    Provider Enumeration Date: 
11/07/2018