Provider First Line Business Practice Location Address: 
1005 S JOSEY LN
    Provider Second Line Business Practice Location Address: 
STE 202
    Provider Business Practice Location Address City Name: 
CARROLLTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-478-2442
    Provider Business Practice Location Address Fax Number: 
972-478-2662
    Provider Enumeration Date: 
01/31/2006