Provider First Line Business Practice Location Address: 
5068 W PLANO PKWY STE 134
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PLANO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75093-4440
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-985-7565
    Provider Business Practice Location Address Fax Number: 
888-664-0571
    Provider Enumeration Date: 
09/15/2006