Provider First Line Business Practice Location Address: 
15948 S POST OAK RD
    Provider Second Line Business Practice Location Address: 
SUITE C
    Provider Business Practice Location Address City Name: 
HOUSTON
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
77053-3645
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-835-9494
    Provider Business Practice Location Address Fax Number: 
281-835-9433
    Provider Enumeration Date: 
08/10/2012