Provider First Line Business Practice Location Address:
25518 WOUNDED KNEE
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:
78261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-319-8333
Provider Business Practice Location Address Fax Number:
830-714-4621
Provider Enumeration Date:
04/10/2006