Provider First Line Business Practice Location Address:
1528 N MAIN AVENUE
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:
78212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-226-8407
Provider Business Practice Location Address Fax Number:
210-226-8420
Provider Enumeration Date:
11/13/2006