Provider First Line Business Practice Location Address:
1816A WEST AVE
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:
78201-3552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-734-7685
Provider Business Practice Location Address Fax Number:
210-734-3719
Provider Enumeration Date:
05/19/2006