Provider First Line Business Practice Location Address: 
130 SPENCER LN
    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: 
78201-2109
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-736-4544
    Provider Business Practice Location Address Fax Number: 
210-732-4035
    Provider Enumeration Date: 
03/25/2008