Provider First Line Business Practice Location Address:
3145 GARDEN AVE BLDG 1278
Provider Second Line Business Practice Location Address:
FORT SAM HOUSTON
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-7718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-808-3735
Provider Business Practice Location Address Fax Number:
860-694-2590
Provider Enumeration Date:
11/16/2005