Provider First Line Business Practice Location Address: 
622 JANISCH RD TRLR 4A
    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: 
77018-2263
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
832-537-2299
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/22/2011