Provider First Line Business Practice Location Address: 
12700 PRESTON RD
    Provider Second Line Business Practice Location Address: 
SUITE 150
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75230-1864
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
972-233-9199
    Provider Business Practice Location Address Fax Number: 
972-233-9799
    Provider Enumeration Date: 
08/01/2006