Provider First Line Business Practice Location Address:
4204 GARDENDALE ST
Provider Second Line Business Practice Location Address:
STE 212
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-549-2986
Provider Business Practice Location Address Fax Number:
210-549-2993
Provider Enumeration Date:
07/20/2010