Provider First Line Business Practice Location Address: 
17480 DALLAS PKWY
    Provider Second Line Business Practice Location Address: 
SUITE 120
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75287-7337
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-783-3581
    Provider Business Practice Location Address Fax Number: 
972-767-3471
    Provider Enumeration Date: 
12/05/2016