Provider First Line Business Practice Location Address:
17425 LUCKEY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATASCOSA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78002-5563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-622-9033
Provider Business Practice Location Address Fax Number:
210-622-3156
Provider Enumeration Date:
01/21/2007