Provider First Line Business Practice Location Address: 
10103 FONDREN RD
    Provider Second Line Business Practice Location Address: 
SUITE: 175
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77096-4556
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-471-5288
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/26/2014