Provider First Line Business Practice Location Address: 
4502 MEDICAL DR
    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: 
78229-4402
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-358-4000
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/09/2021