Provider First Line Business Practice Location Address:
4204 GARDENDALE ST.
Provider Second Line Business Practice Location Address:
STE 203
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-614-8452
Provider Business Practice Location Address Fax Number:
210-614-8561
Provider Enumeration Date:
10/10/2006