Provider First Line Business Practice Location Address: 
6800 TELEPHONE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FORT WORTH
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
76135-2856
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
817-306-4200
    Provider Business Practice Location Address Fax Number: 
817-237-3271
    Provider Enumeration Date: 
02/07/2007