Provider First Line Business Practice Location Address: 
7322 LYIA BR
    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: 
78252-2749
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
281-413-4361
    Provider Business Practice Location Address Fax Number: 
210-354-7114
    Provider Enumeration Date: 
05/14/2007