Provider First Line Business Practice Location Address: 
AVE DE DIEGO 150
    Provider Second Line Business Practice Location Address: 
SAN JUAN HEALTH CENTER SUITE 510
    Provider Business Practice Location Address City Name: 
SAN JUAN
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00907
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-724-6755
    Provider Business Practice Location Address Fax Number: 
787-723-4513
    Provider Enumeration Date: 
01/04/2006