Provider First Line Business Practice Location Address: 
6800 WEST LOOP S
    Provider Second Line Business Practice Location Address: 
SUITE 580
    Provider Business Practice Location Address City Name: 
BELLAIRE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77401-4528
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
713-255-7996
    Provider Business Practice Location Address Fax Number: 
713-255-0637
    Provider Enumeration Date: 
04/29/2015