Provider First Line Business Practice Location Address:
14603 HUEBNER ROAD BLDG 1
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78230-7823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-468-5426
Provider Business Practice Location Address Fax Number:
210-764-5440
Provider Enumeration Date:
10/20/2005