Provider First Line Business Practice Location Address: 
4415 W PIEDRAS DR
    Provider Second Line Business Practice Location Address: 
SUITE 208
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78228-1216
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-733-9929
    Provider Business Practice Location Address Fax Number: 
210-733-9916
    Provider Enumeration Date: 
10/04/2006