Provider First Line Business Practice Location Address:
147 E MISTLETOE AVE
Provider Second Line Business Practice Location Address:
STE. 105
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-858-8144
Provider Business Practice Location Address Fax Number:
210-370-9979
Provider Enumeration Date:
02/28/2006