Provider First Line Business Practice Location Address: 
4403 NW LOOP 410
    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: 
78229-5122
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-340-1800
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/02/2006