Provider First Line Business Practice Location Address:
302 E NAKOMA ST
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:
78216-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-377-1234
Provider Business Practice Location Address Fax Number:
210-308-0210
Provider Enumeration Date:
07/11/2005