Provider First Line Business Practice Location Address: 
814 AMAROSA RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DALLAS
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
75217-8093
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
469-236-4913
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/28/2015