Provider First Line Business Practice Location Address:
3145 GARDEN AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1278
Provider Business Practice Location Address City Name:
JOINT BASE SAN ANTONIO - FSH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-295-4095
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/21/2006