Provider First Line Business Practice Location Address:
55 CALLE DR BASORA 55 NORTE EDICICIO MEDICO IV
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
MAYAGUEZ
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00680-0111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-833-4865
Provider Business Practice Location Address Fax Number:
787-265-4757
Provider Enumeration Date:
12/27/2005