Provider First Line Business Practice Location Address: 
12468 MEMORIAL DR
    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: 
77024-6100
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-465-8655
    Provider Business Practice Location Address Fax Number: 
713-465-9062
    Provider Enumeration Date: 
08/03/2006