Provider First Line Business Practice Location Address: 
543 PINN 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: 
78227-1233
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-670-1105
    Provider Business Practice Location Address Fax Number: 
210-670-0962
    Provider Enumeration Date: 
04/25/2007