Provider First Line Business Practice Location Address:
6603 INGRAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78238-4107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-225-7003
Provider Business Practice Location Address Fax Number:
210-225-7760
Provider Enumeration Date:
10/17/2006