Provider First Line Business Practice Location Address:
12610 LA PLATA ST
Provider Second Line Business Practice Location Address:
12610 LA PLATA ST.
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78233-6334
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-542-4972
Provider Business Practice Location Address Fax Number:
210-599-0704
Provider Enumeration Date:
06/06/2012