Provider First Line Business Practice Location Address: 
13998 HORIZON BLVD STE 140
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HORIZON CITY
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
79928-6599
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
915-852-0852
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/07/2011