Provider First Line Business Practice Location Address: 
CARRETERA NUMERO 2 KILOMETRO 69.3
    Provider Second Line Business Practice Location Address: 
BARRIO SANTANA
    Provider Business Practice Location Address City Name: 
ARECIBO
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00612-0000
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
939-268-8515
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/24/2007