Provider First Line Business Practice Location Address:
1001 PAT BOOKER RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
UNIVERSAL CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78148-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-723-8309
Provider Business Practice Location Address Fax Number:
830-980-4463
Provider Enumeration Date:
11/01/2005