Provider First Line Business Practice Location Address: 
248 MEMORIAL CITY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77024
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-468-6648
    Provider Business Practice Location Address Fax Number: 
713-468-1731
    Provider Enumeration Date: 
09/29/2006