Provider First Line Business Practice Location Address:
9310 BROADWAY ST
Provider Second Line Business Practice Location Address:
SUITE 201 BLDG 2
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78217-5907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-824-6801
Provider Business Practice Location Address Fax Number:
210-824-6886
Provider Enumeration Date:
11/07/2005