Provider First Line Business Practice Location Address: 
343 W HOUSTON ST
    Provider Second Line Business Practice Location Address: 
SUITE 503
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78205-2107
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-225-4251
    Provider Business Practice Location Address Fax Number: 
210-225-4254
    Provider Enumeration Date: 
07/14/2011