Provider First Line Business Practice Location Address: 
14526 OLD KATY RD STE 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77079-1047
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-744-8953
    Provider Business Practice Location Address Fax Number: 
636-552-6692
    Provider Enumeration Date: 
05/18/2009