Provider First Line Business Practice Location Address: 
1900 HI LINE DR
    Provider Second Line Business Practice Location Address: 
#401
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75207-3333
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-841-8092
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/08/2012