Provider First Line Business Practice Location Address:
1632 PAT BOOKER RD
Provider Second Line Business Practice Location Address:
SUITE 124
Provider Business Practice Location Address City Name:
UNIVERSAL CITY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78148-3552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-945-9226
Provider Business Practice Location Address Fax Number:
210-566-5914
Provider Enumeration Date:
07/21/2006