Provider First Line Business Practice Location Address: 
BARRIADA MARIN CALLE CARLOTA NUM 79 A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GUAYAMA
    Provider Business Practice Location Address State Name: 
PR
    Provider Business Practice Location Address Postal Code: 
00784
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
787-375-4991
    Provider Business Practice Location Address Fax Number: 
787-844-4130
    Provider Enumeration Date: 
09/13/2010