Provider First Line Business Practice Location Address: 
19750 STATE HIGHWAY 46 W STE 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SPRING BRANCH
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78070-6881
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
830-438-2193
    Provider Business Practice Location Address Fax Number: 
830-438-2196
    Provider Enumeration Date: 
08/18/2025