Provider First Line Business Practice Location Address: 
13111 WESTHEIMER RD
    Provider Second Line Business Practice Location Address: 
SUITE #212
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77077-5546
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-230-3804
    Provider Business Practice Location Address Fax Number: 
832-230-3839
    Provider Enumeration Date: 
09/19/2012