Provider First Line Business Practice Location Address:
2323 W ILLINOIS AVE
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:
75224-1637
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-331-5466
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2006