Provider First Line Business Practice Location Address: 
4522 FREDERICKSBURG RD
    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: 
78201-6521
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-732-1802
    Provider Business Practice Location Address Fax Number: 
210-732-1804
    Provider Enumeration Date: 
07/27/2009