Provider First Line Business Practice Location Address: 
633 GOV CARLOS G CAMACHO RD
    Provider Second Line Business Practice Location Address: 
STE 101 GUAM MEDICAL PLAZA
    Provider Business Practice Location Address City Name: 
TAMUNING
    Provider Business Practice Location Address State Name: 
GU
    Provider Business Practice Location Address Postal Code: 
96913-3143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
671-646-3855
    Provider Business Practice Location Address Fax Number: 
671-646-3854
    Provider Enumeration Date: 
08/31/2005