Provider First Line Business Practice Location Address: 
12800 HILLCREST RD
    Provider Second Line Business Practice Location Address: 
SUITE123
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75230-1524
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-681-9800
    Provider Business Practice Location Address Fax Number: 
972-681-9804
    Provider Enumeration Date: 
02/23/2007