Provider First Line Business Practice Location Address: 
8207 CALLAGHAN RD
    Provider Second Line Business Practice Location Address: 
STE. 425
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78230-4735
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-414-7558
    Provider Business Practice Location Address Fax Number: 
281-398-9719
    Provider Enumeration Date: 
06/20/2011