Provider First Line Business Practice Location Address: 
17115 IH 35 N STE 123
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SCHERTZ
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78154-1468
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-539-0847
    Provider Business Practice Location Address Fax Number: 
210-539-2107
    Provider Enumeration Date: 
01/08/2025