Provider First Line Business Practice Location Address: 
3436 S POLK ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75224-3804
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
214-371-2815
    Provider Business Practice Location Address Fax Number: 
214-371-0606
    Provider Enumeration Date: 
11/17/2006