Provider First Line Business Practice Location Address: 
17700 N US HIGHWAY 281
    Provider Second Line Business Practice Location Address: 
SUITE 320
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78232-1404
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-495-6255
    Provider Business Practice Location Address Fax Number: 
210-495-6260
    Provider Enumeration Date: 
07/24/2006