Provider First Line Business Practice Location Address: 
5222 WHISPERING OAKS DR
    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: 
75236-1740
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-636-7834
    Provider Business Practice Location Address Fax Number: 
940-293-9911
    Provider Enumeration Date: 
05/08/2013