Provider First Line Business Practice Location Address:
3629 FAIRMOUNT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75219-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-415-2830
Provider Business Practice Location Address Fax Number:
214-522-8619
Provider Enumeration Date:
10/13/2006