Provider First Line Business Practice Location Address: 
13431 BLANCO RD
    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: 
78216-2188
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
830-302-7360
    Provider Business Practice Location Address Fax Number: 
830-837-5230
    Provider Enumeration Date: 
06/04/2021