Provider First Line Business Practice Location Address: 
1025 GARNER FIELD RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
UVALDE
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78801-4809
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
830-278-6251
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/06/2014