Provider First Line Business Practice Location Address: 
4407 FM 1960 RD W
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77068-3409
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-397-6161
    Provider Business Practice Location Address Fax Number: 
281-397-6167
    Provider Enumeration Date: 
06/13/2012