Provider First Line Business Practice Location Address: 
106 AND A HALF E OAK ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
DENTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76201-4240
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
940-352-0000
    Provider Business Practice Location Address Fax Number: 
940-382-0000
    Provider Enumeration Date: 
01/09/2007