Provider First Line Business Practice Location Address: 
2135 CARR 2
    Provider Second Line Business Practice Location Address: 
WALGREENS DRUG STORE 00710 DRIVE IN PLAZA
    Provider Business Practice Location Address City Name: 
BAYAMON
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00959-5240
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-785-9176
    Provider Business Practice Location Address Fax Number: 
787-785-9223
    Provider Enumeration Date: 
07/01/2011