Provider First Line Business Practice Location Address:
2139 SAN JACINTO BLVD
Provider Second Line Business Practice Location Address:
UNIVERSITY OF TEXAS ATHLETICS, NEZ B1.024A
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-232-3939
Provider Business Practice Location Address Fax Number:
512-232-5054
Provider Enumeration Date:
12/19/2014