Provider First Line Business Practice Location Address:
213 HAZEL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78207-7705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-226-2814
Provider Business Practice Location Address Fax Number:
210-224-0164
Provider Enumeration Date:
12/14/2006