Provider First Line Business Practice Location Address: 
11745 W IH 10
    Provider Second Line Business Practice Location Address: 
770
    Provider Business Practice Location Address City Name: 
SAN ANTONIO
    Provider Business Practice Location Address State Name: 
TX
    Provider Business Practice Location Address Postal Code: 
78230-1048
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
210-696-6546
    Provider Business Practice Location Address Fax Number: 
210-696-6901
    Provider Enumeration Date: 
09/27/2006