Provider First Line Business Practice Location Address: 
CARR. 653 KM 2.0 SECTOR BARRANCA
    Provider Second Line Business Practice Location Address: 
HATO ABAJO
    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: 
787-879-5700
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/27/2023