Provider First Line Business Practice Location Address:
1007 W THEO AVE
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:
78225-1849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-317-8854
Provider Business Practice Location Address Fax Number:
210-922-6633
Provider Enumeration Date:
12/23/2005