Provider First Line Business Practice Location Address: 
CARR. #2 KM 30 SECTOR ESPINOSA 17-D
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VEGA ALTA
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00692
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-915-6224
    Provider Business Practice Location Address Fax Number: 
787-915-6223
    Provider Enumeration Date: 
10/04/2012