Provider First Line Business Practice Location Address:
2490 7TH ST
Provider Second Line Business Practice Location Address:
BLDG 372
Provider Business Practice Location Address City Name:
FORT SAM HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234-7613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-223-1104
Provider Business Practice Location Address Fax Number:
210-223-3810
Provider Enumeration Date:
06/05/2007