Provider First Line Business Practice Location Address: 
14114 DALLAS PARKWAY
    Provider Second Line Business Practice Location Address: 
STE 200
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75254-1301
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-373-9092
    Provider Business Practice Location Address Fax Number: 
214-373-9250
    Provider Enumeration Date: 
03/01/2011