Provider First Line Business Practice Location Address: 
8301 BROADWAY ST
    Provider Second Line Business Practice Location Address: 
SUITE 419
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78209-2006
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-805-0555
    Provider Business Practice Location Address Fax Number: 
210-805-0556
    Provider Enumeration Date: 
07/29/2008