Provider First Line Business Practice Location Address:
1222 MCCULLOUGH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212-4812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-223-4140
Provider Business Practice Location Address Fax Number:
210-359-6640
Provider Enumeration Date:
12/01/2005