Provider First Line Business Practice Location Address: 
4 CALLE HOSPITAL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CIALES
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00638-3310
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-871-2003
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/31/2007