Provider First Line Business Practice Location Address: 
3880 GREENHOUSE RD
    Provider Second Line Business Practice Location Address: 
SUITE 412
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77084-6792
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-418-2479
    Provider Business Practice Location Address Fax Number: 
888-462-7208
    Provider Enumeration Date: 
08/13/2011