Provider First Line Business Practice Location Address: 
13535 JONES MALTSBERGER RD
    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: 
78247-3928
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-496-5437
    Provider Business Practice Location Address Fax Number: 
210-496-2804
    Provider Enumeration Date: 
11/14/2006