Provider First Line Business Practice Location Address: 
600 S CONROE MEDICAL DR STE 101
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CONROE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77304
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
936-242-6957
    Provider Business Practice Location Address Fax Number: 
936-242-6958
    Provider Enumeration Date: 
02/28/2007