Provider First Line Business Practice Location Address: 
5301 N GARLAND AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GARLAND
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75040-2716
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-535-0253
    Provider Business Practice Location Address Fax Number: 
972-535-0253
    Provider Enumeration Date: 
12/08/2011