Provider First Line Business Practice Location Address: 
8415 FREDERICKSBURG RD
    Provider Second Line Business Practice Location Address: 
UNIT 906
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78229-3173
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-585-8282
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/17/2014