Provider First Line Business Practice Location Address: 
AVE 65 INFANTERIA K.3.4
    Provider Second Line Business Practice Location Address: 
BARRIO SABANA LLANA
    Provider Business Practice Location Address City Name: 
SAN JUAN
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00924
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-765-1650
    Provider Business Practice Location Address Fax Number: 
787-765-1650
    Provider Enumeration Date: 
11/22/2005