Provider First Line Business Practice Location Address: 
CARR 869 KM 2.0 PALMAS VILLAGE
    Provider Second Line Business Practice Location Address: 
BO. PALMAS
    Provider Business Practice Location Address City Name: 
CATANO
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00962
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-620-8120
    Provider Business Practice Location Address Fax Number: 
787-620-8267
    Provider Enumeration Date: 
12/30/2005