Provider First Line Business Practice Location Address: 
URB SAN LORENZO 2 CALLE PEDRO MORA
    Provider Second Line Business Practice Location Address: 
SUITE 1
    Provider Business Practice Location Address City Name: 
ARECIBO
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00612
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-817-2512
    Provider Business Practice Location Address Fax Number: 
787-816-7364
    Provider Enumeration Date: 
06/08/2006