Provider First Line Business Practice Location Address: 
17006 SAN PEDRO AVE
    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: 
78232-2231
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-494-4606
    Provider Business Practice Location Address Fax Number: 
210-494-0150
    Provider Enumeration Date: 
04/03/2007