Provider First Line Business Practice Location Address:
250 E BASSE RD STE 107
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:
78209-8409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-224-4811
Provider Business Practice Location Address Fax Number:
210-224-1573
Provider Enumeration Date:
04/13/2012