Provider First Line Business Practice Location Address: 
4020 NACO PERRIN BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78217-2579
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-644-8900
    Provider Business Practice Location Address Fax Number: 
210-644-8925
    Provider Enumeration Date: 
07/15/2011