Provider First Line Business Practice Location Address: 
2460 N INTERSTATE HIGHWAY 35 E STE 165
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
WAXAHACHIE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75165
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-506-2617
    Provider Business Practice Location Address Fax Number: 
972-788-4707
    Provider Enumeration Date: 
03/22/2006